Patient Forms

The following forms and corresponding instructions have been provided for your convenience. Please note that these forms may not be the appropriate forms for all patients in all circumstances.

New Patient Forms

New patients can save time during their first appointment by completing the Patient Registration form prior to their visit. Simply print out the Patient Registration form, fill in the information requested, and bring the completed form with you to your appointment.

• • Patient Registration
  • HIPAA Privacy Notice
  • Patient Consent to Treatment
  • Patient Financial Policy
  • Patient Bill of Rights
  • No Show Policy
  • Medical Release Form to SRMG

Wellness and Routine Exam Forms

Patients seeking a routine preventive exam (annual physical) should read the Routine Preventive Exam document below before their appointment.

• Medicare Annual Wellness
• Annual Wellness Visit Welcome Packet

Medical Records Request

To have medical records released, please complete the Authorization to Disclose Protected Health Information form, which is located below. You can also find information in the Patient Portal.

• Medical Release Form from SRMG

Immunizations

Confused about what immunizations your health plan covers? This helpful checklist will guide you through the conversation with your health plan before your next visit if it may include immunizations.

• Immunizations: Parent-Friendly Schedule for Children, Birth through 6 Years
• Immunizations: Parent-Friendly Schedule for Preteens and Teens, 7-18 Years
• Immunizations: Recommended Adult Immunization Schedule for ages 19 years or older
• Vaccines & Immunizations