Forms

All forms are provided in PDF format

PHOTO IDENTIFICATION
A valid picture ID is required. This ID can be a driver’s license, passport, military ID, state issued ID, or employment badge.

HIPAA and PATIENT RIGHTS

• HIPAA Privacy Notice (PDF)
• Patient Rights & Responsibilities (PDF)

REGISTRATION FORMS (COMPLETE FOR ALL SERVICES EXCEPT DOT SUBSTANCE TESTING ONLY)

• Authorization to Treat Form (PDF)
• Non-Injury Patient Registration and Consent (PDF)
• Injured Worker Patient Registration and Consent (PDF)
• HIPAA Authorization to Release Form (PDF)

DOT SUBSTANCE TESTING

• DOT Substance Testing Registration Form (PDF)
• HIPAA Authorization to Release Form (PDF)

WORKERS' COMP

• Comprehensive Patient History for Workers' Comp Injuries (PDF)
• First Report of an Injury, Occupational Disease or Death (PDF)
• Medication Reconciliation Form (PDF)

PHYSICAL EXAMS

• Ambulette Exam Medical History (PDF)
• Immigration Exam Medical History (PDF)
• Periodic Exam Medical History (PDF)
• School Bus Driver Exam Medical History (PDF)

IMMUNIZATIONS

• Hepatitis A Consent Form (PDF)
• Hepatitis A Fact Sheet (PDF)
• Hepatitis B Consent Form (PDF)
• Hepatitis B Fact Sheet (PDF)
• MMR (Measles, Mumps, Rubella) Consent Form (PDF)
• MMR (Measles, Mumps, Rubella) Fact Sheet (PDF)
• Tetanus Consent Form (PDF)
• Tetanus Fact Sheet (PDF)
• Tuberculosis Test Consent Form (PDF)
• Travel Questionnaire (PDF)
• TWINRIX (Hepatitis A and B combination) Consent Form (PDF)

MEDICAL SURVEILLANCE

• Hearing Questionnaire (English/Spanish) (PDF)
• Initial Asbestos Questionnaire (PDF)
• Periodic Asbestos Questionnaire (PDF)
• OSHA Respirator Questionnaire (English/Spanish) (PDF)

For further information or to schedule an appointment, contact us.