Patient Forms

Complete your forms online

All of our patient paperwork is available digitally. Sign in to the patient portal to fill out and submit any of the forms below — your information is kept private and secure.

You'll be asked to sign in with Google before submitting a form.

Patient Intake

Tell us about yourself, your health history, and your medications.

~10 min

Start this form

Consent to Treat

Consent to receive medical care, including telehealth.

~4 min

Start this form

Consent to Bill / Financial Responsibility

Acknowledge the membership model and financial terms.

~4 min

Start this form

HIPAA Authorization

Authorize the use and disclosure of your protected health information.

~5 min

Start this form

Medication List

List your current prescription medications.

~5 min

Start this form

Patient–Provider Agreement

The Direct Primary Care membership agreement and its terms.

~8 min

Start this form

Credit Card Authorization

Authorize recurring membership charges. Download, complete, and return this form to the office.

PDF

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