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Forms

Certain forms are required to be filled out prior to receiving care at our facilities. For your convenience, we have provided these forms here for you to download, complete and bring in with you on your visit to our office. If you have a special form that needs to be utilized (such as Sports Physical or Corporate Physical Paperwork), please bring that with you as well.

Private Patients

Services paid for by Patient or Patient’s Insurance Company

For All Private Patients on Every Visit

• Patient Registration – Private (pdf)
• Patient Authorization – Private (pdf)

Additional Forms Required For Private Patients for Injury Care, Treatment of Illness or Wellness Visit

• Patient Health History (pdf) - Only completed once a year, updated if changes occur
• Problem List (pdf) – Only completed once a year, updated if changes occur
• Medication List (pdf) – Only completed once, updated on each visit

Corporate Patients

Services paid for by Employer, Workers Compensation Carrier, Lab or Third Party Administrator

For Employers to send with their employee needing services

• Treatment Authorization Form (pdf)

For All Corporate Patients Required on Every Visit (other than a Workers Compensation Recheck)

• Patient Registration – Corporate (pdf)
• Patient Authorization – Corporate (pdf)

Additional Forms Required For Corporate Patients Receiving Injury Care or Physical Exam

• Patient Health History (pdf) – For Workers Comp/injury Care and Physical Exam patients on their initial visit

Forms for Specific Services

(Corporate or Private Patients)

Medical Records Release for Patients. Have a copy of your records forwarded to our office

• Medical Records Release (pdf)

For Patients receiving Respirator Clearance

• OSHA Questionnaire (pdf)

For Patients receiving Flu Vaccine

• Flu Consent Form (pdf)

For patients receiving PPD/TB Testing

• PPD/TB Testing (pdf)