855-501-1004
Arizona Patient Forms
Please fill out only if requested.
Additional New Patient Forms:
- Professional Disclosure
- HIPAA Notice of Privacy Practices and Acknowledgment of Receipt
- Consent to Treat
- Telehealth Informed Consent
- Consent to Receive Emails & Text Messages
- Consent to Obtain Medication History
- Acknowledgment of Financial Responsibility
- Authorization for Disclosure of Minor Health Info to Parent-Guardian
- Disclosure Authorization Form Primary Care
- Disclosure Authorization Form – Other Providers
- Credit Card Authorization
- Consent to Medications
- Patient Health Screen Child
- Patient Health Screen Adult
- Patient Self-Pay Agreement
- Qualifying Telemedicine Referral Form