Patient Forms

New Patient Paperwork

Please complete the forms on the “Book Appointment” page before arriving for your appointment as a new patient. Be sure to bring a valid, government issued photo ID. We also ask that you bring a current copy of your insurance card as this will be submitted with any laboratory or pathology specimens.

Book Appointment

Additional Forms

Telemedicine Consent Form

Telemedicine Consent Form – Secure Online Form

Medical Records Release

This form is used when you would like to request your medical records.

Medical Records Release – Secure Online Form

Privacy Policy

This form is used for you to acknowledge our Privacy Policy.

FDL Privacy Policy – Secure Online Form

Family and Friends Release

This form is used if you would like to give our office permission to speak to someone other than yourself regarding your personal medical history, office visits, pathology results, etc.

Family and Friends Release – Secure Online Form

Third Party Release

This form is used when a third party, such as a life insurance company, is requesting your medical records.

Third Party Release – Secure Online Form

Please note that there may be a fee associated with releasing your records; this office policy is listed in our new patient paperwork.

Authorization for Disclosure of Protected Health Information

Authorization for Disclosure of Protected Health Information – Secure Online Form

Minor Consent Form

FDL Minor Consent – Secure Online Form

HIPPA Privacy Practices