Patient Forms

To help you save time during your visit to our clinic, we’ve made our most common forms available on the web! Just print the forms, fill them out when convenient, and bring them along for your appointment.

New Patient Packet

The New Patient Packet contains all three forms that we ask our patients to fill out during their first visit. You’ll need Adobe Reader to view and print these forms.

New Patient Packet


Medical Records Form

Records Release: If you would like us to release your records to another physician, download and fill out this form and Fax to our office at (574)269-7444.

Records Release Form

Records Request: If you have records from another medical practice that would be helpful to our providers, download and complete this form and send it to your previous physician.

Records Request Form


Individual Forms

Each form included in the New Patient Packet is also available for individual download. You’ll need Adobe Reader to view and print these forms.

Registration Form

Patient Health History

HIPAA Acknowledgement

 
 
 



COVID-19 Notice - Updated Mask Rules

Updated May 14, 2021

In keeping with the recent CDC masking recommendations, if you can provide proof of your completed COVID-19 vaccination, you will not be required to wear a mask in our office.

If you are not vaccinated or unable to present proof you will still be required to wear a mask while in our office. Children and visitors are not allowed to accompany you during your appointment at this time.