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Forms

Please complete the 3 forms below to prepare for your visit.

General Visit Information

Please complete this form before your visit.

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Patient Last Name

Patient First Name

Patient Middle Initial

Date of Birth

Sex
MFOther

Primary Care Physician

Social Security #

What is the main reason(s) for your visit today?

Allergies

Please Select
None/No Known AllergiesLatexRubber (bandiads, tape, spandex, balloons)Sulfa DrugsOther

Medication Allergies

Please list all medications that you have allergies to, and your reaction to them.

Medications

Preferred Pharmacy Name

Preferred Pharmacy Location

Current Medications

Please list ALL medications you are currently taking. Please include the name of medication, dosage, and frequency.

History

Personal Medical Problems:(Cancer, Diabetes, Hypertension, Stroke, etc.)

Previous Surgeries

Family Medical Problems:(Father, Mother, Siblings, Grandparents)

Tobacco Use
NeverCurrent

Tobacco Use: Number of Years (optional)

Alcohol Use
NeverCurrentPast

Alcohol Use: Number of Years (optional)

Alcohol Use: Years Since Quitting (optional)

Recreational Drug Use
NeverCurrent

Health Information Release

Please complete this form before your visit.

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Authorization to Release Health Information To: (EXAMPLE: Spouse/Parent, Parent, Child)

Name(s) Separate with a ","

Phone Number

Date From:

Date To:

Authorization Expires:
Never1 Year2 Years5 Years10 YearsOther

Release the following information
All RecordsChart NotesRadiology ReportsLab ReportsOther

Date

Printed Name of Patient or Legal Representative

Date of Birth

If signed by Legal Representative, Relationship to Patient

Medical Records Release

Please complete this form before your visit.

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Patient Name

Date of Birth

Patient Address

I hereby authorize you to release medical records from:

Facility Name/Provider

Phone Number

Fax Number

Dates of service requested

Information to be released: (Please check all that apply including specific date range) This authorization
will expire upon 1 year from date of execution and the undersigned may revoke this authorization in writing.

Entire Medical RecordChart NotesRadiology Report(s)Lab &/or Pathology Report(s)Other

Please email records to: [email protected]

Or mail records to: 295 5 1470 E, STE 301

St. George UT 84790

P: 435-775-20L5 F:435-775-2016

Date

Patient Signature



Prefer a physical copy instead?

Download a copy of the required forms here.

Forms

Please complete the 3 forms below to prepare for your visit.

General Visit Information

Allergies

Medication Allergies

Medications

Current Medications

History

Health Information Release

Authorization to Release Health Information To: (EXAMPLE: Spouse/Parent, Parent, Child)

Medical Records Release

I hereby authorize you to release medical records from:

Prefer a physical copy instead?

Phone: (435) 775-2015

Fax: (435) 775-2016

[email protected]

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295 S 1470 E Suite 301 St George, UT 84790