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Patient Forms

Family History Questionnaire
FMLA Completion Request Form
Advance Consent to Treat Minor*
Only one patient and only one authorized individual may be listed on the Advance Consent to Treat Minor form. If you have more than one child or more than one authorized individual, you must complete separate forms.
*Foster Children: unless arrangements have been made by the caseworker, all foster children must be accompanied to the appointment by their foster parent or caseworker only. Please call our office if you have questions.
Advance Consent to Treat Unaccompanied Minor (16+)
Teenagers will still need to have a parent with them for first-time visits and if they are seeing a specialist for any reason, including allergy shots.
Over 18 HIPAA Consent Form
As of a patient’s 18th birthday, parents and/or guardians are no longer be permitted access to medical records, healthcare information, providers, and or appointment status without specific written permission. If you would like to give your parents and/or guardians access, please complete this form.