Patient Resources

Patient Forms

Please print and complete all forms below that apply to you. Also remember to bring your insurance card(s) and your current medications on your first visit.

Please plan to arrive at least 15 minutes prior to your first visit so that you may be properly registered. Thank you for allowing us to help you.

New Patient Forms

• Registration
• Financial Responsibilities

Questionnaires

• Health History Questionnaire
• Sexual Health Inventory for Men (SHIM) (Males Only)
• AUA Symptom Score (AUASS) and Quality of Life (QOL) (Males Only)

Medical Records Request

• Authorization for Use or Disclosure of Protected Health Information
  (If applicable)

Notice of Privacy Practices

• Acknowledgement of Notice of Privacy Practices and Patient Consent