value. quality care. convenience
PATIENT FORMSBelow you will find a list of common informational and medical forms. Click on the button below the document's description to download a printable copy. Completed forms may be faxed 3-4 days prior to the time of service to (706) 322-2080, or brought in 3-4 days prior to the time of service, or can be mailed at least 3-4 days prior to the time of service to the following address:
Chhokar Clinic You can be assured - we have a commitment to excellence when it |
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NEW PATIENT |
MEDICAL RELEASE |
FINANCIAL POLICY |
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New Patient Registration Form - Required for all new patients. This form allows us to register you into our practice as well as provides us with a brief medical history of any problems you may be experiencing. Also attached is a copy of our privacy practices. |
Medical Records Release Form - Authorizes us to release your medical records to an individual or another doctor's office. |
Financial Policy and Insurance Requirements - Information related to established policies within our practice. |
CREDIT CARDS |
COUMADIN CONSENT |
DIAGNOSTICS INSTRUCTIONS |
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Credit Card Pre-Authorization Form - Required to authorize recurring credit card charges or standard payments to the clinic. |
Consent for Warfarin (Coumadin®) Educational Material and Consent Form. |
NST Instruction Sheet - Important instructions that must be signed and returned to the clinic prior to any Nuclear Stress Test. |
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Tel 706-322-0528 |
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© Chhokar Clinic |
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