Patient eForms

Annual Consents | e-Sign

• Print Form

• Formulary Benefits Data, Communications Consent, Telemedicine Consent, Notice of Privacy, & Privacy Practices 

• These consents are required every 12 months prior to seeing a provider in our office.

HIPAA Medical Release Form

• • Print Form

  • Electronically complete and sign this form so that we can review your medical records from other medical providers, facilities, and or hospitals.  Please note, line #7 is most important so that we can contact your former providers.  

  • You may complete more than one form, if needed.

  • If you have no recent hospital visits, urgent care visits, or no prior medical follow up there is no need to complete this form.

Screening Forms | e-Sign

Payment Plan Form | e-Sign

Payment Plan | Recurring Payment Authorization Form

• Print Form

• Use this form to authorize recurring payments towards your medical bills (e.g, copays, coinsurance, self-pay fees, etc).

• For verification purposes please remember to bring the credit or debit card that you will be using to authorize future payments.

Isotretinoin Consents | e-Sign

iPLEDGE - Females

• Please review the following resources:

  • 1. Guide to Isotretinoin for Female Patients Who Can Get Pregnant 

  • 2. Birth Control Workbook

• Then, please sign the consent form below prior to your office visit.

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