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Patient Forms

To expedite your check-in process, you may print and fill out some of the following paperwork prior to your visit.

For Our New Patients:

  • Welcome Form [PDF] – Please print this form and complete it to the best of your ability.
  • Activity Sheet [PDF] – Please print this form and fill out either the left side if you are over 18 years of age or the right side if you are under 18 years of age.
  • Privacy Practices [PDF] – Please simply review our privacy practices prior to your visit. You are not required to print this form or bring it with you to your visit. (Updated 11/3/2014)
  • Policy Form and Acknowledgement of Notice of Privacy Practices Form [PDF] – Please print and complete this form after reviewing the Privacy Practices. Include your signature and date under “Section 1,” and a signature and date under “Section 2.”

For Our Returning Patients:

  • Privacy Practices [PDF] – Please simply review our privacy practices prior to your visit. You are not required to print this form or bring it with you to your visit. (Updated 5/30/2014)
  • Policy Form and Acknowledgement of Notice of Privacy Practices Form [PDF] – Please print and complete this form after reviewing the Privacy Practices. Include your signature and date under “Section 1,” and a signature and date under “Section 2.”

To Request a Release of Your Records:

  • Request for Release of Records [PDF] – Complete this form if you’d like your medical records released to another clinic or into your possession. Please review and complete sections 1-8 and make a copy of your photo ID. You may return this document to us by bringing it to the clinic,  you may fax it to (651) 452-1564, or you may e-mail it to our Public Information Officer.

To Request Release of Identifying Health Information

  • Request Release of Identifying Health Information [PDF] – Complete this form if you’d like another person(s) to have access to your records. Please review and complete sections 1-3 and sign, date, and time this form. You may return this document to us by bringing it to the clinic,  you may fax it to (651) 452-1564, or you may e-mail it to our Public Information Officer.