Patient Forms

Thank you for choosing CFM for your medical needs.

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICESAuthorization For Release or To Request Medical Informationpatient insurance and billing informationnotice of privacy practicespatient portal informationpatient portal meaningfuluseNew Patient information

Gender:
Birth Date(Required)
Address
Phone Type

Spouse/Partner Information

Marital Status:
Address (if different than Patient
Phone Type

Emergency Contact Information

Insurance Information

Policy Holder's Date of Birth

Medical History

Are you currently being treated by a physician?
Do you have any allergies/sensitivities to medications or Latex
Check if you have had any of the following:

Authorization

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my medical status. I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance.
MM slash DD slash YYYY