The following forms are available for you to print and complete at your convenience prior to your appointment. If you wish to send us completed forms, fax them to (928) 770-5356. We request you call us at (928) 424-4444, option 2 to confirm we received any form(s) you faxed to us.
New Patients Forms
The Patient Information Form above includes basic demographic and insurance information. Along with this form, we will need to see a photo id and proof of insurance (both front and back of the card). Our front desk section will you will need to get copies of your ID (like a driver’s license) and insurance card (both the front and back). The front desk will confirm the provided information.
The Medical History Form above needs to be as complete as possible. It will be reviewed with you at your first appointment.
Pregnancy Patients Forms
The New Pregnancy Form above needs to be as complete as possible. It will be reviewed with you at your first appointment.
The HIPAA Consent Form above will allow us to disclose your protected health information to the individual(s) you select.You will be reviewing our notice of privacy practices at your first appointment with us.
The Medical Release Form above will allow us to make copies of your medical records for yourself or another healthcare provider.