Forms

Get Access to Important Forms Online

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 forms 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 below, complete them before your appointment and bring them with you. If you have questions, please contact us at (510) 248-1000.

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

• New Patient Registration
• Patient Medical History Questionnaire
• Medical Records Release Form

Policies & Practices

• Financial Policy
• HIPAA Notice of Privacy
• Notice of Privacy Practices

Forms From Specific Services

Seasonal Flu

• CDC Vaccine Information Sheet (VIS)
• Vaccine Consent & Registration Form

Orthopaedic Surgery & Sports Medicine

• Medical History Form

Psychiatry and Behavioral Science

• Medical Worksheet
• Medication Consent Form

Surgery

• General Surgery Medical History Form
• Mammography Questionnaire (for breast health patients only)

Urology

• Patient History Questionnaire
• Review of Systems Questionnaire
• Child's Genitourinary History Questionnaire
• Female Patient Genitourinary History Questionnaire
• Male Patient Genitourinary History Questionnaire
• AUA Symptom Score and Quality of Life Questionnaire

Washington Women's Health Specialists –– OB/GYN

• Forms available at this link

Women's Center

• Mammography Questionnaire