Patient forms

ONLINE FORMS:

• New Patient Letter
• Patient registration form
• Consent for medical care
• Authorization form for use and/or disclosure of protected health information
• Designating others involved in your care
• Pre-Authorized payment form
• Acknowledgement and authorization payment policy

FORMS MAILED TO YOU:
In order to provide you with the best possible care, we ask you to complete all forms before your first visit. Each form is described below. Please bring the completed forms to your office visit. DO NOT MAIL THESE FORMS.

1. History Questionnaire
2. Quality of Life Questionnaire
3. Bladder Diary. Please follow the directions on this sheet. A standard one cup measuring devise may be used to measure volume in ounces or cc's. Your doctor will provide you with this form at your first visit.
4. IMPORTANT - Please bring a current medications list or your medicine bottles to your first visit.
5. IMPORTANT - Please bring old medical records, operative reports and urine culture results that might be pertinent to your condition.
6. IMPORTANT - Please bring your insurance card(s) when you come to our office.