The forms below are provided for your convenience and can be completed prior to arriving for your appointment.
This form gives consent for a designated adult to provide and arrange medical care for a minor child that is not accompanied by either parent or legal guardian.
Portal Family Access For Patients with Special Healthcare Needs
Virtual Visit Forms
SPORTS FORM INSTRUCTIONS: – Complete part one. If there are any “yes” answers please include a brief written explanation. – In order for the MD to sign part 2, part 1 must be completed for the MD to review. – Include the following information on the sports form:
- Patient’s name and date of birth
- Phone number and fax number (if applicable)
- When the form is due
- How you would like us to return the completed form. Options include: fax, mail, pick up at front desk, or email (through our patient portal) Please allow 2-3 days for us to complete the form.
IMPORTANT!!! If the patient’s most recent physical was over 2 years ago we CANNOT sign the form.