REGISTRATION AND MEDICAL FORMS:
Insurance Status Form:
 *Please print and complete*

&

LLC

Phone: 770-343-9112
Fax: 770-343-8911
Complete Physical Questionnaire
  *If you appointment is with Dr. David Boaz, please print this form and complete prior to your appointment.
Instructions for an ADULT complete physical. If you have any questions, please contact our office.
Consent to vaccinate. Must be completed for all patients 18 and under.
Refusal to Vaccine. Instruction on how to complete and form to complete with your physician. This form is for Adults and Children.
Sports Physical Form. Please complete parent section prior to your appointment.
MEDICAL RELEASE FORMS:
HIPPA Consent Form:
 *Please print and complete*
Financial Statement
 *Please print and complete*
Registration Form
 *Please print and complete*
NEW PATIENT FORMS:
PHYSICAL FORMS (Under Age 18):
Records release to be sent to another physician or patient. Fees may apply.
Release for SFFMP to receive your records.
HIPPA & PHI INFORMATION:
HIPPA INFORMED CONSENT INFORMATION FOR ALL PATIENTS..
PHI FORM (for age 18 and over, consent to contact and speak with other persons besides the patient)
Authorization For Another Person Other Than Parent or Legal Guardian to Bring Child To Apppointment(s).

*Future Pictures*





*Future Pictures*





PHYSICAL FORMS (Over Age 18):
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HIPPA ACKNOWLEDGMENT SIGNATURE SHEET. PLEASE SIGN AFTER YOU VIEW THE HIPPA INFORMED CONSENT.
Personnel HealthCare Record (PHR) Patient Information.
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