Forms

Patient Registration Form (PDF)

Information required from our new patients.

Patient Medical History (PDF)

Medications, allergies, past/current medical issues, hospitalization and surgical history, family and immunization history are all factors to consider.

Medical Information Release (PDF)

Allows patients to give permission for their health information to be shared with a specific person, firm, organization, or facility.

Financial Policy (PDF)

This form informs patients that they are solely responsible for all medical services they receive, regardless of insurance eligibility or coverage determinations.

No Show and Cancellation Policy (PDF)

This form includes our no show and cancellation policy and requires an agreement signature from all patients.

Female System Review & Checklist (PDF)

Female specific review of systems and symptom checklist.

Male System Review & Checklist (PDF)

Male specific review of systems and symptom checklist.

Consent to Obtain Medication History (PDF)

Allows patients to give permission for their medication history to be obtained through a patients pharmacy, health plans, and other health care providers.

Notice of Privacy Practices Acknowledgement Form (PDF)

Describes how health information about you (as a Care Center patient) may be used and disclosed, as well as how you can obtain access to your personally identifiable health information. Please read this message thoroughly.

Virtual Visit Policy (PDF)

Allows patients to give permission for their health information to be shared with a specific person, firm, organization, or facility.

Patient Rights Information Packet (PDF)

This packet covers your rights and our duties to you, as well as your options for what information we can share with you and how we normally use and share your data.