New Patients:
- Patient Facesheet
- Patient History Questionnaire
- Practice Financial Information
- Email and Office Procedures
- Authorization to Disclose Protected Health Information
- Medicare Secondary Form
- Medical Records Release Form
If you are coming in for one of the following chief complaints, please complete the appropriate forms.
These forms are doctor specific:
Ear Infection:
- Adult Ear Infection Questionnaire- Dr. Segebrecht
- Child Ear Infection Questionnaire- Dr. Segebrecht, Dr. Martinez, or Dustin R. Huff, PA-C
Dizziness:
- Dizziness Questionnaire- Dr. Reussner, Dr. Martinez, Tanya Robb, APRN, or Dustin R. Huff, PA-C
- Dizziness Questionnaire – Dr. Segebrecht
Hearing Loss:
Sinuses:
Tonsils:
Allergy: