Pre-registration Forms

October 24, 2016

In order to better serve you, we have several forms available for you to download and fill out in advance of your appointment. Please bring your completed forms with you to your appointment.

Forms are listed by Care Center. Please carefully choose only the forms listed under the office and/or physician, as indicated, where and/or with whom you have an appointment! (Please note that Centennial Care Center physician and the physicians at our Summit Care Center have additional or individual forms that should be completed.)

In addition to Care Center-specific forms, all patients are asked to read our Privacy Policy. Patients should then download and print the Privacy Practices Acknowledgment form. Please bring completed forms to your first office visit. Thank you.

NOTE: Download and print the forms, fill them out and bring them with you for your visit.

CENTENNIAL CARE CENTER
pdficon.jpg?w=640 Patient Registration Intake Form
pdficon.jpg?w=640 Medical History form
pdficon.jpg?w=640 Consent to Treat Form (for unaccompanied minors)

HARDING PLACE CARE CENTER
pdficon.jpg?w=640 Patient Registration Intake Form
pdficon.jpg?w=640 Medical History Intake Form
pdficon.jpg?w=640
Consent to Treat Form (for unaccompanied minors)
pdficon.jpg?w=640 WC Referral and Intake Form.

HENDERSONVILLE CARE CENTER
pdficon.jpg?w=640 Patient Registration Intake Form
pdficon.jpg?w=640 Medical History Form

LEBANON CARE CENTER
pdficon.jpg?w=640 Patient Registration Intake Form
pdficon.jpg?w=640 Medical History Form

MRI CENTER
pdficon.jpg?w=640 Patient Registration Intake Form

SKYLINE CARE CENTER
pdficon.jpg?w=640 Click Here For The Patient History and Physical Form
pdficon.jpg?w=640 Patient Registration Intake Form
pdficon.jpg?w=640 Consent to Treat Form (for unaccompanied minors)

STONECREST CARE CENTER
pdficon.jpg?w=640 Patient Registration Intake Form
pdficon.jpg?w=640 Medical History Form

SUMMIT CARE CENTER
pdficon.jpg?w=640 Patient Registration Intake Form
pdficon.jpg?w=640 Medical History Form
pdficon.jpg?w=640 Consent to Treat Form (for unaccompanied minors)

PRIVACY POLICY (HIPAA)
New patients are asked to read our pdficon.jpg?w=640 Notice of Privacy Practices.
After reading the Notice of Privacy Practices, new patients should download the pdficon.jpg?w=640 Privacy Practices Acknowledgement form to complete and then take to their first visit.