Forms

(Please click on any form or question to view and/or to print.)

Introductory Information for Our Patients

Lifespan Family Healthcare

New Medical Patient Forms 

Intro, Patient Information, Health History, Financial Policy, Consent & Disclosure, and Medical Release (packet)

Pediatric New Medical Patient Forms
Patient Consent Release/Financial Policy (included in packet above)

Medical Records Release form  (included in packet above)
Notice of Patient Privacy (HIPAA)  (to view or print)

New Counseling Patient Forms

New Counseling Patient Packet

Primary Care Provider Release

Adult Screen

Miscellaneous forms or information (to view or print)

Forms for Annual Exam/Physical  

Forms for Annual Wellness Visit 
Pediatric Annual Visit Forms

HealthInfoNet Opt Out
Flu Vaccine Consent Form
Flu Vaccine Information Statement (CDC)

What is an ABN?

ABN form
Advanced Directive form
What is a PA?
What is Marriage and Family Therapy?
Patient Satisfaction Survey form
Insurance and Payment Policies
Preventative Exam Information

Driver Medical Evaluations

Disability Placard