Patient Forms

New Patient Forms

Full Packet

WHASN Patient FormsDownload
Formularios para pacientes de WHASNDownload

Individual Forms – English

Acknowledgement of Receipt of the Notice of Privacy PracticesDownload
Authorization for Release of Medical InformationDownload
Authorization for the Use and Disclosure of Medical InformationDownload
Consent for Obtaining Retaining or Disclosing Genetic Information in NevadaDownload
E-Prescribing PBM Consent FormDownload
Financial Policy AgreementDownload
Medical HistoryDownload
Notice of Privacy PracticesDownload
Patient Notification of Advance Directive AvailabilityDownload
Patient PortalDownload
Patient RegistrationDownload
Release of Protected Health InformationDownload
Request for Amendment of My Medical RecordDownload
Request for Confidential Communications of My Medical RecordDownload
Request for Restrictions on Uses and/or Disclosures of My Medical RecordDownload
Revocation of My Authorization for the Use and Disclosure of Medical InformationDownload

Individual Forms – Español

Acuse de recibo del aviso de prácticas de privacidadDownload
Autorización para la divulgación de información médicaDownload
Autorización para el uso y divulgación de información médicaDownload
Consentimiento para obtener, retener o divulgar información genética en NevadaDownload
Formulario de consentimiento de PBM para recetas electrónicasDownload
Acuerdo de política financieraDownload
Historial médicoDownload
Aviso de prácticas de privacidadDownload
Notificación al paciente de la disponibilidad de directivas anticipadasDownload
Portal de pacienteDownload
Registro de pacientesDownload
Divulgación de información médica protegidaDownload
Solicitud de enmienda de mi historia clínicaDownload
Solicitud de comunicaciones confidenciales de mi historia clínicaDownload
Solicitud de restricciones sobre usos y/o divulgaciones de mi expediente médicoDownload
Revocación de mi autorización para el uso y divulgación de información médicaDownload

Forms for Pregnant Patients

Consent for Vaginal Birth After Cesarean SectionDownload
Consentimiento para el parto vaginal después de una cesáreaDownload
Fetal Kick Count RecordDownload
Registro de conteo de patadas fetalesDownload
Genetic Testing Options & Consent FormDownload
Opciones de pruebas genéticas y formulario de consentimientoDownload
Refusal for Genetic Screening Consent FormDownload
Negativa a realizar el cribado genéticoDownload
Ultrasound Consent FormDownload
Ultrasonido en el embarazoDownload

Surgery and Procedure Information and Consent Forms

Colposopy ConsentDownload
D&C with Hysteroscopy Information & ConsentDownload
Endometrial Ablation Information & ConsentDownload
Endometrial Biopsy ConsentDownload
Genetic Carrier Screening Information & ConsentDownload
IUD Insertion ConsentDownload
IUD Removal ConsentDownload
Laparoscopic Tubal Ligation Information & ConsentDownload
Laparoscopy Information & ConsentDownload
LEEP Information & ConsentDownload
Myomectomy Information & ConsentDownload
Nexplanon Insertion ConsentDownload
Nexplanon Removal ConsentDownload
Salpingo Oophrectomy Information & ConsentDownload
Suction D&C Information & ConsentDownload
Total Laparoscopic Hysterectomy Information & ConsentDownload

To view the forms listed above, you will need Adobe Reader. You may download Adobe Reader for free at www.adobe.com. Please bring your completed forms with you to our office at the time of your visit.