• New patients – complete the registration form below prior to appointment
  • Well Child Checks – complete the appropriate development form below prior to appointment
  • Phone Nurse Triage
  • Sick Visits
  • Minor procedures
  • Ear Piercing
  • Hospitalist Services at Columbus Community Hospital

*****Forms completed electronically will be automatically and securely submitted to our clinic*****

Important Medicaid Changes

Section 1: Registration Forms

All new patients or patients who have not been seen in our clinic within the last 3 years must fill out the registration form before the appointment

Section 2: Policies

The following three forms must be filled out by all patients once a year.

Financial Responsibility Form

Notice of Health Information Privacy Practices & Acknowledgement of Receipt of Notice of Privacy Practices Form

Patient Consent and Authorization Form

Section 3: Forms by Age

Please fill out the appropriate forms based on the patient’s age and/or type of appointment.

Sports Physical Form – All sports & band participants

Adolescent Form – 11 years and older

Mothers Forms – 2 month, 4 month, and 6 month appointments

Forms

Formularios