Forms/Visit Information

Please print, complete and bring to your next office visit.

• HIPAA Privacy Notice - read only
  
  
• Financial Responsibility and Acceptance
  
  
• Prescription Record
  
  
• Release of Information:
  
  
  • to AALFA
  • from AALFA
  • to a personal representative
    
    
• Authorization to Treat a Minor:
  
  
  • Consent
  • Allergy; unaccompanied minor
    
    
• Insurance/Payment Information