Forms

New Patients please complete the following forms:

 

If forms are completed arrive 20 mins prior to appointment with insurance card/photo ID and medical records. Please note new patients that do not call to cancel a first appointment are considered a “No-show” and are not allowed to schedule future appointments. We appreciate all patients arriving a few minutes early so that we are able to see all patients at their scheduled times. New patients should bring their insurance cards and a list of all medications in use to the first visit.

 

Patient Demographic Form required

Notice Of Privacy Practices (pdf) required

SAMC Policies and Procedures (pdf) required

Portal Authorization (pdf) required

Authorization For Release Of Information (pdf) Only if your records are being transferred from or to another physician

Patient General Information  (pdf) required for 18yrs & older

Pediatric Health History Form (pdf) required for 0-17 yrs

Preventive care exam consent Form (pdf) required