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New Patient Registration Forms
(Please, download and fill out all five forms.)
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Form 1
(.PDF format)
(Top of form is blank.)
Form 2
(.PDF format)
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Form 3
(.PDF format)
Form 4
(.PDF format)
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Consent for Use and Disclosure
of healthcare information
(.PDF format)

Consent To Operation, Anesthetics, and Other Medical, Dental & Surgical Services
(.PDF format)

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Oral Sedation Preoperative Instructions
(.PDF format)

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Postoperative Instructions
(.PDF format)

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Halcion Information and Consent Form
(.PDF format)

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Consent for Use and Disclosure of Healthcare Information

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Adobe Acrobat
.PDF format
(Preferred)
HTML format

PatientFinance.Com Credit Application
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Adobe Acrobat
.PDF format
(Preferred)
HTML format

Request Alternative Means and/or Location for Communication of Healthcare Information
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Adobe Acrobat
.PDF format
(Preferred)
HTML format

Request for Healthcare Information
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Adobe Acrobat
.PDF format
(Preferred)
HTML format

Request for Accounting of Disclosures of Healthcare Information
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Adobe Acrobat
.PDF format
(Preferred)
HTML format

Appointment or Cancellation of Personal Representative for Disclosure of Healthcare Information
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Appointment
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Appointment
Adobe Acrobat
.PDF format
(Preferred)
HTML format

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Cancel
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Cancel
Adobe Acrobat
.PDF format
(Preferred)
HTML format

Request for Added Restrictions on Healthcare Information
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Adobe Acrobat
.PDF format
(Preferred)
HTML format

Request for Amendment of Healthcare Information
download PDF download html
Adobe Acrobat
.PDF format
(Preferred)
HTML format
 

Phone 205-854-7448


Suite 100
2500 Center Point Road
Center Point, AL 35215
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