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New Patients
Forms you need to download - please print all forms, fill them out and bring them or mail them to us prior to your first visit. If we would like to receive these forms at least 2 business days before your first appointment. Please put your name on every page.

You will need Adobe Reader to access these forms. Click Adobe Reader to download the reader.

Some patients have had difficulty printing these Adobe files. Do not try to print these forms by clicking the Print button on your Internet browser - if you do, you will print a blank page. To print each form, you need to click on the Print button inside the Adobe Reader program.

If you are not able to print the forms off the Internet, we can mail them to you, if there is time. If you can't get the forms by Internet or in time by mail, please come to our office to pick up these forms. They have to be sent back to us immediately.

1. Patient Profile Form. Please print this profile form and fill it completely before coming to our office. You must complete the 'Insurance information' section. If your spouse is the policy holder, we require BOTH your social security number and your spouse's social security number.

2. Consent form that allows us to treat you, allow release of information, and assignment of benefits. Print this agreement which has to be signed before you can be seen in our office.

3. Medical History. Please print this three page form and complete it - this data will be entered on the office computer and becomes part of medical record. Please put your name on every page. You can print this form by clicking on the Print Form button on the top of the form or on the Print button inside the Adobe Reader program. We prefer you not email this form. Mail, fax or dropping off the forms is more reliable and secure.

4. HIPAA Notice of Privacy Practices and Contact Information. Please click and print this form. Don't forget to fill out the Contact Information section and bring it with you to your visit.

5. Consent for Message or Text. Signing this form allows us to leave you a phone message or text

These forms are required, so print and review them right away. Fill them out and get them to us at least 2 business days prior to your appointment. Please put your name on every page

Copyright 2017 Center for Colon and Rectal Surgery, U.S.A. All rights reserved.