Patient Forms
Online Patient Forms
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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.
IF YOU ARE HAVING A ULTRASOUND APPOINTMENT, YOU DO NOT NEED TO FILL OUT A FORM.
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 3. 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) |
Dexa Scan Forms
For patients coming in for a Dexa Scan please fill out the form #1 below and bring it with you to your appointment.To prepare for your appointment please wear comforable, loose clothing.Do not wear clothing with metal items such as zippers, snaps, buttons or buckels.Do not take any Tums, Rolaids or any other calcium supplement for 24 hours before your appointment.Removal navel rings, if applicable.Dexa machine has a 350 lb weight limit.1. Dexa Questionnaire |
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 3. Update your Protected Health Information Authorization (HIPAA) Form |
Consent to Obtain Medical Information: Use the following form if you need your previous physician to send your records to us. Consent for Medical Information |
Quality Care Forms
| Patient Satisfaction Survey |
| Health Care Proxy |
| Notice of Privacy Practices |
