Patient Registration Forms & Privacy Notices
If you are a new patient, please fill out the registration forms listed below in advance of your appointment to assist the staff in making sure that we have all the information necessary to provide you with quality care and treatment. Please bring the completed forms with you to your appointment.
Registration Forms
- Patient Registration
- Patient Acknowledgement and Consent
- Financial Policy
- Initial Clinical History and Physical Form
- Pediatric Health History
- Infant Health History
- Adult Immunization Release
- Medical Records Release
- Personal Health Information Release
- Informed Consent
- Medicare Second Payor
- Patient Fee Letter
- Formulario de Inscripción
- Autorizacion de Entrega de Information de Cuidado de Salud
- Concentimiento Para Pacientes
- Póliza Financiera
- Consentimiento Del Paciente Para Communication Financieras
- Historial de Salud ninos de 2 a 16 anos de edad
- Informacion Historial de Salud
- Formulario de Consentimiento Para Adultos - ImmTrac
- Medicare Secundaria Pagador
- Notice of Privacy Practices (provided for you at your first visit)
- Aviso Sobre Las Practicas De Privacidad (proporcionada por usted en su primera visita)
Formularios de Inscripción de Pacientes
Patient Rights & Responsibilities
We respect our patients’ dignity and pride. This document will explain your patient rights and responsibilities. It is part of your patient registration and is an important part of your health care plan.
Patient Rights & Responsibilities
Derechos y Responsabilidades del Paciente
Privacy Notices
This privacy notice describes how health information about you may be used and disclosed and how you can get access to this information. Please review it carefully.