Patient Forms

If you are a new patient to our office, the files below contain the forms that will need to be filled out when you arrive at our office. Printing them, filling them out and bringing them with you will allow us to attend to your medical needs more quickly than completing them on your arrival.

Our offices are equipped with secure "Electronic Medical Records" software. This feature will help us to function as medical home for you.

Thank you and please call our office at 304-724-7200 if you have any questions.

New Patient Information Form

Medical History Form

Authorization to Release Healthcare Information

Insurance Waiver

Insurance Non-Participation Waiver

Insurance Obligation Waiver

Patient Consent for Use and Disclosure of Protected Health Information

Flu Vaccine Consent Form

School Medication Order Form

School Participation / Physical Form

Commercial Driver Fitness Determination Form

 

 

This web site uses files in Adobe Acrobat Portable Document Format (pdf) which require Adobe® Acrobat® Reader for viewing and printing. It is available to download free.