FOR NEW PATIENTS
Please complete the following 3 forms prior to your appointment, Patient Demographic Sheet, HIPAA Form, and Medical History Form. These forms are necessary for clinic registration (Medical Records Release is not necessary for New Patient Registration). While we prefer that you complete your forms online, (They will be emailed to us directly), you may also print, complete and bring the forms to your appointment.
- Patient Demographic Sheet (Printable PDF)
- Patient Demographic Sheet (Online Form)
- Medical History Questionnaire (Printable PDF)
- Medical History Questionnaire (Online Form)
- New Patient HIPAA Consent (Printable PDF)
- New Patient HIPAA Consent (Online Form)
CONSENT TO TREAT A MINOR FORM (When applicable)
MEDICAL RELEASE REQUEST FORM (When applicable)
A request of medical records must be in writing, dated and signed by the person making the request, and include a reasonable description of the records sought. If someone is making a request on your behalf, he or she must provide evidence of the authority to receive the records (such as power of attorney).
Upon receipt of the request, the provider has 15 days to do one of the following:
- Provide copies of the records;
- Inform the requester if the information does not exist or cannot be found; or
- Inform the requester of the provider who now maintains the records;
ADOV will maintain patient records for a minimum of six years following the last patient encounter barring any other exceptions where ADOV is required to maintain them for longer.