New Patient Forms

*** New patients: please complete and sign the Registration form & HIPAA signature page and bring them to your first appointment. Thank you. ***

New Patient Registration Paperwork
New Patient Registration Form.pdf
Adobe Acrobat document [56.4 KB]
HIPAA page 1
HIPAA pg 1.pdf
Adobe Acrobat document [2.3 MB]
HIPAA page 2
HIPAA pg 2.pdf
Adobe Acrobat document [2.0 MB]
HIPAA signature page
HIPAA signature pg.pdf
Adobe Acrobat document [441.9 KB]

Release of Records Forms

Authorization for records to be released FROM Loar, Heble, and Knight Family Physicians
Authorization to release records_2014.pd[...]
Adobe Acrobat document [93.1 KB]
Request for records to be acquired by our office
To have records transferred TO our office, please fill out this form and either present it to the facility currently holding the records, or fax, mail, or bring this form to our office.
Request for records to be acquired.pdf
Adobe Acrobat document [76.8 KB]

Medicare Annual Wellness Visit Questionnaire

Medicare Annual Wellness Visit form
If you are on Medicare and have an upcoming Annual Wellness visit, please complete this form and bring it with you to your appointment.
AWV Questionnaire.pdf
Adobe Acrobat document [123.0 KB]

Miscellaneous Forms

Motrin Infant Dosage
infants_dosage.gif
Graphic interchange format [5.5 KB]
Infant and Childrens Tylenol Dosage
tylenol.gif
Graphic interchange format [14.6 KB]

Websites

Information on Advance Directives and Advance Care Planning

 

Caring Connections

 

National Healthcare Decisions Day