Patient Forms

Patient Registration Forms & Privacy Notices

If you are a new patient, please fill out the registration forms listed below in advance of your appointment to assist the staff in making sure that we have all the information necessary to provide you with quality care and treatment. Please bring the completed forms with you to your appointment.

Registration Forms

• Patient Registration and Consent
• Medical Records Release
• Patient HIPAA Acknowledgement and Consent
• Consent To Treat/Financial Consent
• Endocrinology New Patient Medical History Questionnaire

Instructions

• Colonoscopy Prep (Fakhruddin, Lewis, Schneider, Stein)
• Colonoscopy Prep (Shah)
• Colonoscopy Prep (Neff)
• EGD Instructions
• ERCP Instructions
• EUS Instructions
• Rectal EUS Instructions

Referral Request Forms

• Endocrinology New Patient Form
• Endoscopy Request Form

Patient Rights & Responsibilities

We respect our patients’ dignity and pride. This document will explain your patient rights and responsibilities. It is part of your patient registration and is an important part of your health care plan.

Patient Rights & Responsibilities

Derechos y Responsabilidades del Paciente

Privacy Notices

This privacy notice describes how health information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

• Notice of Privacy Practices (provided for you at your first visit)
• Aviso Sobre Las Practicas De Privacidad (proporcionada por usted en su primera visita)