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Patient Forms

Instructions:

  1. Please click each link below to download the required forms for your appointment and print them off.

  2. Please read each document thoroughly and complete to the best of your ability.

  3. Please bring the filled out forms with you for faster service at your appointment.

    These forms are required and include specific instructions, please fill and review all information carefully. If you have any questions please feel free to either use our online contact form or give us a call at: (406) 327-4395

 

  • Personal Information and HIPPA Notice of Privacy Practices:

    • Please fill out this form (FRONT & BACK) to the best of your ability then sign the bottom of the front and back. The back of this form describes how medical information about you may be used by our office and/or a third party as well as giving our office permission to share your info with said parties.
  • Financial Agreement:

    • Please carefully read the front and back of this form then sign on the line at the bottom. This is an explanation of your responsibility as our patient to update your information, ensure your financial cooperation and general expectations we have for our patient clientele. By signing, you agree to uphold our policies.
  • Contact Information:

    • Please give any and all contact information possible, indicate your preferred contact and whether we are allowed to leave a message at any of these possible forms of contact.
  • Insurance Agreement:

    • Please read this form carefully as it concerns and explains our protocol for payment before and after ALL appointments. Initial next to one of the two options that applies personally to you then sign and date the bottom line.
  • Patient & Family History:

    • Please fill out both of these forms (FRONT & BACK) to the best of your ability and list any additional questions or concerns at the bottom of the last page.
  • Cancer Risk Assessment:

    • ONLY patients at risk for cancer need to fill out this form. If applicable, please fill out this form to the best of your ability, the doctor will review it with you during your appointment.

Thank you so much for completing all of our paper work to the best of your ability, we do understand this isn’t the most fun and your time is very valuable to us, we do truly appreciate it.  Please return all paperwork to reception when it is completed, thank you!!!

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