Forms
During your appointment, you will need to answer some important questions so that you and your health professional can plan your care together. The following forrms are provided to you as tools to help you prepare for and make the most of your doctor visit.
To save time, you may print the forms and complete them before your appointment, and bring them with you.
Please remember to bring a current list of your medications, a current insurance card and your co-pay along with your completed forms to your appointment.
Patient Information/History
16. Patient Medical History Questionnaire
Policies and Practices
3. Notice of Privacy Practices for the Usage and/or Disclosure of Protected Health Information
4. Authorization for Disclosure of Health Information
5. Notice of Privacy Practices
6. Acknowledgement of Receipt of Privacy Practices
7. Financial Policies - Spanish (Poliza Financial - Espanol)
Cardiovascular and Thoracic Surgery
24. Patient History Questionnaire
Immunizations
10. Screening Questionnaire for Adult Immunization
11. Screening Questionnaire for Child and Teen Immunization
Orthopedics
12. Screening Questionnaire for New Orthopedic Patients
13. Screening Questionnaire for Orthopedic Hip Patients
14. Screening Questionnaire for Orthopedic Knee Patients
15. Screening Questionnaire for Orthopedic Shoulder Patients
Pediatrics
23. Pediatric Health Questionnaire
Surgery
8. General Surgery Intake Questionnaire
Thoracic and Foregut Surgery
25. Patient History Questionnaire
Urology
17. Patient History Questionnaire
18. Review of Systems Questionnaire
19. Child's Genitourinary History Questionnaire
20. Female Patient Genitourinary History Questionnaire
21. Male Patient Genitourinary History Questionnaire
22. AUA Symptom Score and Quality of Life Questionnaire
