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Patient Forms
Download and complete these forms before your visit to save time and ensure we have all the information needed to provide you with the best possible care.
New Patients: Please complete the New Patient Registration Form and Medical History Questionnaire before your first appointment. Additional forms may be requested based on your specific needs.
New Patient(2)
Consent Forms(2)
Medical Records(2)
Functional Medicine(1)
DPC Membership(1)
Tools(1)
All Forms
Click on any form below to download it as a PDF. You can complete these forms digitally or print them out and bring them to your appointment.
New Patient
FeaturedNew Patient Registration Form
Basic information form for all new patients including contact details, emergency contacts, and insurance information.
125 KBUpdated: January 2025
Download FormNew Patient
FeaturedMedical History Questionnaire
Comprehensive health history including past medical conditions, surgeries, medications, and family history.
186 KBUpdated: January 2025
Download FormFunctional Medicine
Functional Medicine Assessment
Detailed questionnaire covering lifestyle, nutrition, stress, sleep, and environmental factors affecting your health.
245 KBUpdated: January 2025
Download FormConsent Forms
Consent for Treatment
General consent form for medical treatment and procedures at Lotus Direct Care.
98 KBUpdated: December 2024
Download FormConsent Forms
Privacy Practices Acknowledgment
HIPAA privacy notice acknowledgment form regarding the use and disclosure of your health information.
112 KBUpdated: December 2024
Download FormDPC Membership
Direct Primary Care Agreement
Membership agreement outlining the terms of our Direct Primary Care services and fee structure.
156 KBUpdated: January 2025
Download FormMedical Records
Medication List Template
Template to list all current medications, supplements, dosages, and frequencies.
75 KBUpdated: January 2025
Download FormMedical Records
Release of Medical Records
Authorization form to request medical records from previous healthcare providers.
92 KBUpdated: December 2024
Download FormTools
Symptom Tracker
Daily symptom tracking journal to monitor your health between visits.
134 KBUpdated: January 2025
Download FormForm Submission Options
Need Help with Forms?
Our staff is happy to assist you with any questions about completing your forms or to help you determine which forms you need.