Office: (435) 775-2015
Fax: (435) 775-2016
295 S 1470 E Suite 301 St George, UT 84790

Forms

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

General Visit Information

Please complete this form before your visit.


    Allergies


    Medication Allergies

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

    Medications

    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.)





    Health Information Release

    Please complete this form before your visit.

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



      Medical Records Release

      Please complete this form before your visit.

        I hereby authorize you to release medical records from:

        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.

        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

        Prefer a physical copy instead?

        Download a copy of the required forms here.