Patient Forms
Online Patient Forms
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Online Prescription Refill |
Download Patient Forms
To
view the forms listed below, you will need Adobe Reader. You may
download Adobe for free. You may bring your completed forms to the
office at the time of your visit.
Current Patient Forms
Please complete forms #1, #2, #3, and #4 before your Annual Exam and bring them with you to your appointment. 1. Existing Patient
Annual History Questionnaire Our office is participating in the Greater Rochester Regional Health Information exchange (RHIO). Please complete the consent form to either Give or Deny your consent to the RHIO. The Patient Information brochure is also available to you. * If you have any questions or wish to contact the RHIO, they can be reached toll-free at 877.865.RHIO (7446) or online at www.GRRHIO.org Please fill out this form when you are coming for your visit with our office. 4. Update your Protected Health Information Authorization (HIPAA) Form |
Other Forms Available for Current Patients: Consent for Release of Medical Information Use this form if you need us to send your records to another party |
| Screening Questionnaire for Vaccinations (HPV, Tetanus, Flu) |
New Mirena IUD Forms
For patients considering the Mirena IUD, please complete the sections on form #1 labeled Patient Demographic Information, Patient Insurance Information, Date of Last Menses, Allergies, Patient Consent and Charge Card Information. Upon completion, please return the form to our office.1. Mirena Specialty Pharmacy Perscription Request Form Also, please review the information on forms #2 and #3. |
New Patient Forms
Please complete forms #1, #2, #3, and #4 before your First Exam and bring them with you to your appointment. 1. New Patient Medical History Questionnaire Our office is participating in the Greater Rochester Regional Health Information exchange (RHIO). Please complete the consent form to either Give or Deny your consent to the RHIO. The Patient Information brochure is also available to you. * If you have any questions or wish to contact the RHIO, they can be reached toll-free at 877.865.RHIO (7446) or online at www.GRRHIO.org Please fill out this form when you are coming for your visit with our office. 4. Update your Protected Health Information Authorization (HIPAA) Form |
Consent to Obtain Medical Information: Use one of the following forms if you need your previous physician to send your records to us. Select the office location where you will be seen: Brighton Office Webster Office Greece Office |
Medical Spa Patient Forms
Laser Treatment Forms For patients receiving Hair Removal, Vein Reduction, or Sun/Age Spot Reduction treatments |
Massage Therapy Forms For patients receiving Pregnancy, Postpartum, or Therapeutic Massage
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Quality Care Forms
| Patient Satisfaction Survey |
| Health Care Proxy |
| Notice of Privacy Practices |
