Burwell Family Medicine	Forms
	^Let Our Family Care for Yours

    Follow these links to the forms, they can be printed directly from your web browser. New patients should complete and bring forms #1,2,3,5 to their first appointment. Returning patients need only to complete and bring in form # 4 and if they have had any recent changes form #1.

1. Patient Demographic Information A must for new patients, and helpful for established patients whose information has changed.

2. Medical Records Release This form is to transfer medical records from your old Doctor into our practice.

3. Past Medical History Form New patients must fill out this form.

4.Review of Systems Form This is helpful to bring in a new form with you for every visit, to better evaluate you changing medical needs.

5. Patient Consent for Disclosure of Protected Health Care Information This form gives our practice permission to disclose protected health information about yourself.

6. Notice of Privacy Practices This form lets you know how we may use your personal information in our office. This is for your information and does not need to be brought in for appointment.

To download all forms at once in a word document use this link: Forms.doc