Patient Forms

Save time at your first visit by downloading and completing your patient forms before you arrive. Bring the completed forms with you to your appointment, or ask our front desk staff for help filling them out.

All forms are PDF files. If you need a printed copy, need help completing a form, or need a form in another format, please call us at (304) 431-5499 and we will be glad to assist you.

Patient Forms (English)

• Patient Registration Form (PDF, 4 pages, 132 KB)
• Patient Information Sheet (PDF, 3 pages, 84 KB)
• Notice of Privacy Practices (PDF, 6 pages, 124 KB)
• Receipt of Notice of Privacy Practices (PDF, 1 page, 66 KB)
• General Medical Procedure Consent (PDF, 2 pages, 91 KB)
• Medical Consent to Treat a Minor (PDF, 2 pages, 77 KB)
• Consent to Receive Lab Results by Mail or Voicemail (PDF, 1 page, 71 KB)
• Controlled Substance Acknowledgement (PDF, 2 pages, 77 KB)
• Sliding Fee Discount Program – Cover Letter (PDF, 1 page, 69 KB)
• Sliding Fee Discount Program – Application (PDF, 2 pages, 77 KB)
• Gender Identity Questionnaire (PDF, 1 page, 70 KB)
• AUDIT Alcohol Use Screening Questionnaire (PDF, 3 pages, 79 KB)

Formularios para Pacientes (Español)