Annual Consents | e-Sign
Formulary Benefits Data, Communications Consent, Telemedicine Consent, Notice of Privacy, & Privacy Practices
These consents are required prior to seeing a provider in our office.
HIPAA Medical Release 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 | 🔔*These forms can also be accessed during a visit Check-In.
Miscellaneous Forms | e-Sign
Recurring Payment Authorization 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:
Then, please sign the consent form below prior to your office visit.