Patient Forms

If you are a new patient who has an upcoming appointment scheduled with us please print the form below, fill it out and bring to your visit. This will make your first office visit go more efficiently!

Don’t forget to bring your insurance card, picture ID and copay to your appointment as well.

Si usted es un nuevo paciente y tiene una cita con nuestra oficina, por favor imprima el siguiente formulario y traigalosa su cita. Esto ayudara que su primera visita se conduzca mas eficientemente.

También, no se olvide de traer su tarjeta de seguro, una forma de identificación con foto y su copay designado.

Patient Forms

Authorization for Release of Medical Information (PDF) - Allows patients to authorize the disclosure of their health information to a designated individual, company, agency, or facility.

Authorization and Consent for Treatment (PDF) - All patients must provide their consent for treatment, communications (calls, emails, and text messaging), and agreement of financial responsibility. Autorización y Consentimiento Para el Tratamiento

Preferred Contacts (PDF) - Patients are encouraged to complete and return the Preferred Contacts Form but it is not required. Contactos Preferidos

Virtual Visit Policy (PDF) - This policy describes the process for the documentation, maintenance, and transmission of information using virtual visit technology.

Patient History Form (PDF)

Formulario de Historial del Paciente (PDF)

Office Policies

Financial Policy (PDF) - This form advises patients of their complete financial responsibility for all medical services received without regard to insurance eligibility or coverage determinations.

Notice of Privacy Practices (PDF) - Describes how health information about you (as a patient of this Care Center) may be used and disclosed, and how you can get access to your individually identifiable health information. Please review this notice carefully.

HIPAA Privacy Notice