Call Ahead Care Line:  (281) 783-8162

Treatment Authorization Form

Please complete the form below before you arrive to the clinic for your appointment. If you have any questions or concerns, please email physicals@nlucc.com or call 281-895-3566 so that we can assist you or your employee prior to the requested visit.  Alternatively, click here to download a printable version of the form. 
Click or drag a file to this area to upload.

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