Patient Information and Registration Forms
All new patients should bring the following four forms, completed, to your first appointment. Or if you are an existing patient but haven’t been seen in the last 3 years, please complete the four forms and bring to your next appointment so we can update our records.
Patient Registration Form
The Patient Registration Form includes basic information about the patient for our records.
Medical History Form
This form helps our physicians understand your medical history and best assess your needs. Complete the version that corresponds to your age.
+ Adult: 18 and Older
+ Adolescent: 10 to 17
+ Child: 10 and younger
Financial Policy Form
In order to reduce misunderstandings, we have adopted the Financial Policy outlined on this form. We require that you read it carefully, initial each numbered section in the space provided, and sign at the bottom prior to the start of any treatment.
HIPAA / Privacy Policy
Our privacy policy aims to protect your personal information and is compliant with the HIPAA Privacy Rule. Please review the policy, and sign to affirm you have read and understand the policy. If you wish to authorize us to share your information with another person, please complete the optional Release of Information section at the end.
Other Forms
Consent to Treat a Minor
A parent or legal guardian is required to accompany a minor child (age 17 or younger) on the first visit. If you would like to give consent for your minor child to be seen in the absence of a parent or guardian on subsequent visits, sign and send the following form with them:
Release of Records To Kachina Family Medicine
Use this form to request your medical records be sent from another provider to Kachina Family Medicine:
Release of Records From Kachina Family Medicine
Use this form to request your medical records be sent from Kachina Family Medicine to another provider, an Insurance company, or other party/institution:
Please Note: There is no charge for records sent directly to another provider; however, other records transfers may require a fee.