Patient Forms

Online Patient Forms

Pay Your Bill Now

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.


Patient Forms

RHIO Consent Form

Our office is participating in the Greater Rochester Regional Health Information exchange (RHIO).  You will be asked to complete the consent form to either Give or Deny your consent to the RHIO when you arrive for your appointment. 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

Consent for Telemedicine Services

Financial Policy

About Our Fees


At the time of your appointment, you will be asked to sign our financial policy. To review prior to your appointment, click the link above

Other Forms Available for Current Patients:

Consent for Release of Medical Information - Use this form if you need to send your records to US

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)

HPV Vaccine Fact Sheet


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 comfortable, loose clothing.
  • Do not wear clothing with metal items such as zippers, snaps, buttons or buckles.
  • 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.

Dexa Questionnaire


Quality Care Forms