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  • Signature and Agreement

    By entering your full name in the contact form, you acknowledge that your name serves as a digital signature and holds the same legal value as a handwritten signature.

    This confirms that all the information you have provided is accurate, and you agree to the terms outlined in our Patient Policies.

    Your name will be used to process your records, consent, and any necessary medical documentation.

  • Download Forms

    For your convenience, you can download and print the forms at home to bring with you to your appointment.

    Download Patient Information Form (PDF)

  • Submit Your Forms

    After filling out the forms, please submit them online to streamline your appointment process.

  • Privacy Notice

    All patient information is kept confidential and is securely stored according to HIPAA guidelines.

    By submitting this form, you consent to the use of your data for medical purposes only.

Patient Information Form

Please provide the following information to help us serve you.
Full Name Date of Birth Address Phone E-mail Emergency Contact Name Enter Emergency Contact Phone Preferred Pharmacy Insurance Provider Insurance Member ID Patient Signature & Date | By signing below, you confirm that the information provided is accurate and agree to the terms outlined in our Patient Policies. HIPAA Privacy Acknowledgment I acknowledge that I have received the Notice of Privacy Practices from Packer Medical Center. Consent for Treatment I consent to medical evaluation and treatment by Packer Medical Center. I understand medical care may include diagnostic testing and treatment. Financial Policy & Billing Agreement I agree to be financially responsible for all services provided. I understand copays and deductibles are due at time of service. Authorization for Release of Medical Records I authorize Packer Medical Center to obtain or release my medical records. Insurance Assignment of Benefits I authorize payment of medical benefits directly to Packer Medical Center Electronic Communication Consent I consent to receive appointment reminders and communications via email, phone, or text message. Telemedicine Consent I consent to receive medical services via telemedicine. I understand telemedicine has limitations and may not replace in‑person evaluation when necessary. No‑Show / Late Cancellation Policy I understand appointments cancelled with less than 24 hours notice or missed appointments may incur a fee. Authorization to Charge Card on File I authorize Packer Medical Center to charge my card for copays, balances, or missed appointment fees. Photo ID and Insurance Card Submission Please attach or upload a copy of your government ID and insurance card. Primary Medical Conditions Current Medications Allergies Past Surgeries/Hospitalizations Family Medical History Submit