FORMS

When you first make an appointment with our office, you will receive an email invitation to register on our Patient Portal where you may electronically enter all your pertinent medical information.  If you fill this out in advance, it will make your office visit go quicker. Please be complete and accurate. Inaccuracies and errors may be rejected by your insurance company and could delay any planned surgery.

We are excited to introduce you to our patient portal. On the portal, you can

  • Securely communicate with your provider
  • View your health information
  • And even manage your family’s care!
  • Access your information anywhere, anytime, via laptop, iPad, or cellphone

 

Alternatively, paper forms are still available and offered in the Adobe Acrobat format. Adobe Reader is available as a free download from Adobe’s web site. You may quickly and easily fill out the forms on your computer, then print them out and bring them with you when you come in for your appointment. The forms may not be saved in this format so you need to have all of your information at hand when you sit down to fill them out and print them.

If you wish, you can print the forms and then fill them out by hand at your convenience prior to coming in for your appointment.

There are three patient packets.

Standard Patient Registration Packet includes: Patient Information Form, General Surgery Patient Questionnaire, Release of Information and Payment of Benefits Form, our Patient Privacy Statement and the Receipt of Privacy Statement Form.

Breast Patient Registration Packet includes: Patient Information Form, Breast Surgery Patient Questionnaire, Release of Information and Payment of Benefits Form, our Patient Privacy Statement and the Receipt of Privacy Statement Form.

Varicose Vein Consult Form Patient Packet includes: Patient Information Form, Varicose Vein Consult Form General Surgery Patient Questionnaire, Release of Information and Payment of Benefits Form, Our Privacy Statement and the Receipt of Privacy Statement Form.

Some of the forms are also available as individual forms:

Medical Information Release Form is used to request that your medical information to be sent to our office from another one of your doctors or a hospital.

 

New Patient Check List

All new patients should review and complete the following checklist. Be sure to bring the following information along with you on your appoint to our office:

    1. Picture ID
    2. Insurance Card
    3. Co-pay for a Specialist
    4. Referral (if required by your insurance plan)
    5. Mammogram films usually provided on a disk (Breast patients only) (Make sure mammogram report is included with the films).
    6. Complete all health information via the patient portal or manually fill out all new patient paperwork.
    7. Current list of ALL medications (can be entered in the patient portal)

Please call (404) 508-4320 if you have any questions regarding any of this information. Thanks, we look forward to seeing you.