Registration Forms

The Office of Jenny Delaleu, FNP-BC

294 W. Merrick Rd., Ste. #1, Freeport, NY 11520 | Tel: 516-279-5484 | Fax: 516-589-7569

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Registration forms, a necessary part of your medical record. Registration forms help us to create an accurate picture of your health and provide you with comprehensive medical treatment. In addition, enjoy the benefits of accessing your medical records to share with other providers and or specialists. This and more, all in one location on our patient portal, Patient Fusion.

In-Office Visit Forms

1. Patient Intake Form

    • Jump start your office visit. Get comfortable, as this is one of the most important forms of your visit. Make sure to try and complete this form prior to your initial visit and with each annual office visit. Your provider will review everything with you during your visit.

    • Please remember, in-office or "face-to-face" (i.e., routine) visits are decided on a case-by-case basis by the medical provider.

2. Consent to Treatment

    • Give our medical providers the okay to examine you, send prescriptions on your behalf, send you to see a specialist, and or get x-rays or other radiology tests, if needed. Please also see our office policies.

3. Review of Systems

  • Tell us what your symptoms before your appointment.

4. PHQ-9 Depression Screening Tool

  • We screen everyone for depression at least once yearly. It's also part of well-known medical guidelines. Kindly click on the button below.

5. 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.

6. 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.

1. TeleHealth Consent

  • This document gives your medical provider consent to engage in a telemedicine (aka, "TeleHealth") visit with you.

  • Learn more about Telehealth visits here.

2. TeleHealth Symptoms Form

  • Please complete this document before your scheduled TeleHealth visit.

COVID-19 Screening/Visit Forms

COVID-19 Screening Form & Consent

  • Please complete and sign this form prior to your Telehealth Visit for COVID-19 testing.

  • Learn more about Telehealth visits here.

TeleHealth Consent

  • This document gives your medical provider consent to engage in a telemedicine (aka, "TeleHealth") visit with you.

Miscellaneous Forms

New York State DMV Vision Screening Report

  • This form is optional for individuals seeking to renew their NYS Driver's License; a nominal fee will be charged.

  • Don't forget to bring your NY State Driver's license.

  • This service is free of charge to all of our established patients.