Patient Forms
Jenny Delaleu, FNP-BC, PLLC * Primary Care Provider * AHA CPR Instructor
294 W. Merrick Rd., Ste. #1, Freeport, NY 11520 * Tel: 516-279-5484 | Fax: 516-589-7569 | Web: www.aihwCo.com
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Common Medical Forms
Common Medical Forms
Annual Consents
Annual Consents
Includes the following mandatory, annual forms:
Formulary Benefits Data
Treatment Consent
Communications Consent
Telemedicine Consent
Notice of Privacy, & Privacy Practices
Complete this legal form carefully to avoid delays in releasing and or obtaining HIPAA secure records on your behalf.
Please note that lines #7 & #8 must be accurate.
Payment Plan Consent
Payment Plan Consent
Payment Plan | Recurring Payment Authorization
Use this form to authorize recurring payments towards your medical bills (e.g., copays, coinsurance, out of pocket fees, etc.).
For verification purposes please remember to bring the credit or debit card that you will be using to authorize future payments.
Screenings
Screenings
PHQ Depression Screening
PHQ Depression Screening
The PHQ-9 helps to identify depression symptoms like low mood, fatigue, and sleep issues.
Measures depression severity to guide treatment decisions.
Used in routine screenings to support mental health care.
The GAD-7 is a recommended screening form for adults at least yearly.
It is used to screen for a range of anxiety disorders from subclinical and occult to major anxiety.
AUDIT-C helps spot risky drinking patterns before habits progress further.
The ASRS-v1.1 ADHD helps screen for ADHD in adults using simple questions.
It checks focus, impulsivity, and forgetfulness based on symptoms.
A high score may suggest further evaluation for a formal diagnosis.
The DMV Vision Test Report (MV-619) is used in New York to confirm a driver's visual acuity when renewing a license.
Checks vision clarity—must meet 20/40 or better in at least one eye.
Required for license renewal.
Valid for up to 12 months from the exam date.
Isotretinoin Consents | e-Sign
Isotretinoin Consents | e-Sign
iPLEDGE - Females
Please review the following resources:
Then, please sign the consent form below prior to your office visit.
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