Forms

form-iconWe know your time is valuable. You can save time in our office by filling out all of our requested forms in advance. All the forms ask for information you might not have with you in our office at the time of your appointment. To help shorten your check-in process please print and fill out each of the forms below and bring them to your appointment. The Bubble Sheet forms ask you for information that is required of healthcare providers for a variety regulatory reason for safeguarding electronic medical records and quality healthcare initiatives. We are required to collect this information and will not be able to have the provider see you without it.  There are fields on these forms that ask for a date, if these sections apply to you, please fill out the date in a MM/YY format next to the requested information. When you arrive at our office, we will have you fill in the actual bubble sheet that gets scanned into your chart. Because you have taken the time to fill out these forms in advance that process will go very quickly. Please don’t hesitate to contact us if you have any questions about these forms.

 

All New Patients

There are 4 forms that you will need to fill out:

Form 1:   Patient Demographics

Form 2:   Patient Health History

Form 3:   Meaningful Use Bubble Sheet

Form 4:   Health History Bubble Sheet

If you would like to have us send your medical records to another provider or facility, please fill out the medical records release form and return it to us.

Release Of Medical Records

Allergy and Asthma Patients

If you are being seen for allergy or asthma evaluation with Dr. Fahrner, please also fill out these forms:

Form 5:   Allergy/Asthma Questionnaire

Form 6: Please fill this out if you have ever been diagnosed with asthma, or are concerned you have asthma 
Asthma control test – age 4-11

Asthma control test – age 12 and over

Form 7: Please fill this out if you are having allergy testing, or have scheduled follow up to review your immunotherapy treatment.  SNOT Questionnaire

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Hay 2 formas que usted tendrá que llenar:

Forma 1:  Datos básicos del paciente

Forma 2:  Historia de Saluddel Paciente

Si desea hacernos llegar sus registros médicos a otro proveedor o instalación, por favor llene el formulario de autorización para registros médicos y de volver a nosotros.

liberación de Registros Médicos