Forms

In order to make your office visit as efficient as possible, our office forms have been provided to you below.  They are in Adobe Acrobat format. If you don't have Acrobat, you can receive your free download copy here.  Using Acrobat, please type out your response in each of the form fields.  Use the Tab key or Mouse to quickly go from field to field.  NOTE: The free Acrobat Reader does not allow your typed-in information to be saved.  Therefore, you will need to print your completed forms, sign and date them, and bring them with you along with your insurance card to our office. 

Appointment Checklist    - print checklist -

Please complete the Patient Information Form & Medical History Form below and present them to our receptionists at the time of your appointment. 

 - Patient Information Form - type out your responses; Tab/mouse-click between fields, and click 'Print'.  Sign and date at the bottom of page 1.  Bring to your office visit.

 - Medical History Form - type out your responses, Tab/mouse-click between fields, and click 'Print'.  Complete page 3 after printing.  Sign and date page 4.  Bring to your office visit.

 - Notice of Privacy Practices - upon your review, print last page, sign and date, and bring to your office visit.

 - Authorization to Release Medical Information - if you want to request any personal health information or your medical file to be sent anywhere, please complete this form and have it mailed or faxed (402-488-1172) to our Medical Records Dept.  If you have any questions, please call (402) 488-3322 ext. 3004.

 

For more information about our participating insurance plans, medical policies, payment policies and hospital affiliations, visit Our Practice page.  For appointment information, please visit our Clinic Schedule page.