Forms & Info

Below is a list of forms (and a description of those forms) used in our practice that our patients can print out and complete and bring with them to their first visit.

These documents are standard Microsoft Word files. Just click the blue download link next to the forms you need and they will downloaded to your computer’s desktop.

Please call our office if you have any questions about which forms you may need.

Initial Patient Information
This long form should be filled out before your first visit with me.  Bring the completed form with you to your first visit.  It asks about your medical, personal, and family histories.  It will help me get to know the reason for your visit and begin the process of helping to guide your care. Download

Records Release Form
Fill out this form and send it to your current and/or previous medical providers so that we may receive copies of your old records.  Download

Consent to Treat Form
This is a standard form for you to sign before your first visit.  Bring the signed consent form with you to your first visit.  It gives me your consent to treat you, with the understanding that I am going to provide the best medical care I can offer.  Download

PHI Disclosure Form
This is a standard form for you to sign before your first visit.  Bring the signed disclosure form with you to your first visit.  By signing it, you understand that I will do my best to keep your personal health information private.  No one will be permitted to see it without your consent.  Download

Notice of Privacy Practices Form
This form outlines our office policy and procedures for keeping your personal health information private.  It is available for your review at any time, online or in our office.  Download

HBGM Review Table
This table is for our patients with diabetes mellitus.  It can be filled out before visits so that we can review your most recent glucose monitoring results.  Download

IP Basal Verification Table
This table is for our diabetic patients using insulin pumps.  It is used to help us verify the settings of your insulin pump.  Download