Patient Care and Office Forms
Here are eight forms you must fill out before your appointment.
These forms can be printed and filled before your appointment, or will be provided by the front desk when you arrive for your visit.
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To print, click on the PDF image. A document will open on a separate tab, with options on the top right corner. Hit the printer image and select your printer's settings to print.
Summary of
Private Practices
This notice describes how medical information about you may be used and disclosed and how you can get access to this information.We know that your medical information is personal to you, and we are committed to protecting the information about you. As our patient, we create medical records about your health, our care for you, and the services and/or items we provide to you as our patient.
Patient Consent Form
This form provides information about how we may use and disclose protected health information about you. The Notice contains a Patient Rights section describing your rights under the law. You have the right to review our Notice before signing this Consent. The terms of our Notice may change. If we change our Notice, you may obtain a revised copy by contacting our office.
Patient Questionaire
This form informs office personnel of which telephone, answering machine, and/ or voicemail they may leave a message on, and who they may leave a message with when it comes to lab results, general medical condition, and your diagnosis (including treatment, payment and health care operation).
Patient Demographics
Office Policies
Patient Medical History
Authorization for Release of Medical Records
This form concerns a patient's general information. Such as; full name, address, phone number(s), date of birth, emergency contact information, employer information, etc.
Here are our office policies on, our office hours, prescription refills, labs and procedures, Medicare patient, and referrals/authorizations.
Our Patient Medical History form notifies the doctor and staff on a patient's current and past diagnoses, preventative exams (and their results), surgical history, social history, current pharmaceutical information and current medication list.
The Authorization for ​Release of Medical Records informs our staff of of which information can be released, and to whom. This information includes, but is not limited to; X-ray reports, EKG results, progress notes, lab test results, etc.
