Forms

To shorten your waiting time in our office, you may want to complete the appropriate forms in advance and bring them with you to your appointment. Otherwise, we will provide you with the forms to complete in our office. To complete the form(s) by hand, download and print the Adobe PDF version. To complete the form(s) on your computer, download, complete, and print the Microsoft Word version.

Patient Information Form (PDF) (Word Doc). For new patients or to update your information, please bring this completed form and your current health insurance card, if applicable, to enter your information into our system.

Expanded Demographics Form (PDF) (Word Doc). To comply with electronic medical records (EMR) policies, all patients are required to submit the expanded demographics form in addition to the above patient information form.

Medication List (PDF) (Word Doc). For new patients, please bring this completed form to record and discuss all current medications.

Notice of Privacy Practice Receipt (PDF) (Word Doc). This form indicates that you have received a copy of the office's HIPAA Policy (found below and provided at your first appointment and then annually).

HIPAA Policy (PDF). This document outlines your privacy and information security as required by law and is for your information only. You do not need to bring this document with you to our office.

Vaccine Information Statements (website). These information sheets produced by the Centers for Disease Control and Prevention (CDC) explain the benefits and risks of various vaccines. You will be provided a statement in the office as required by law for any vaccinations you receive.

Flu (Influenza) Vaccine Information Statement (PDF). This form is provided by Sanofi Pasteur, the manufacturer of Fluzone and Fluzone HD vaccines.