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Patient Forms

Patient Registration Form - Full Version

This registration form is used to collect basic patient demographic information to register you and initiate your health record.  Please use this version if you are a new patient to our practice.

Patient Registration Form - Annual Update Version

This registration form is required annually to ensure that your demographic information is current in our system.  Please use this version if you are an existing patient at our practice.

Protected Health Information Release Form - Authorization To Release Information To Our Practice

This form is required to give us permission to obtain protected health information from your previous health care provider or other source per your request.  Please use this form to release information to our practice.

Protected Health Information Release Form - Authorization To Release Information From Our Practice

This form is required to give us permission to release protected health information to another health care provider or other recipient per your request.  Please use this form to release information from our practice.

Adult Health Questionnaire

This form is used to collect prior medical history.  This form is typically requested of new patients to our practice to familiarize the provider with the patient's past medical history and to facilitate the initial new patient appointment.

 

©2009 Wentworth-Douglass Physician Corp., PO Box 458, Dover, NH 03821-0458