New Patient Forms
These forms are part of the new patient registration process. Printing out the forms and completing them in advance can save you time at your first visit.
If you need help with any portion of these forms, our Patient Service Representatives are happy to help you.
New Patient Forms
New Patient Intake Form
All patients must complete this form. It gives us basic information and consent to provide care. You will receive an electronic Patient Intake Form electronically.
Release to Obtain Records Form
This required form allows us to request records from your previous healthcare provider. If you do not have a prior healthcare provider, please let us when scheduling your first appointment.
Release to Obtain Records Form
Personal Representative Forms (add or cancel)
A personal representative is someone you authorize to be involved in your health care.
- Complete this form if you want to allow our staff to speak with a spouse or another individual regarding your health care. This includes conversations such as rescheduling appointments or questions on billing issues.
Personal Representative Form - Complete this form if you want to cancel a previously designated Personal Representative.
Cancelation of Personal Representation
Learning Assessment Form
Completing the “What’s your Learning Style” questionnaire helps ensure we provide educational material in the best manner possible.
Learning Assessment Form - English
Learning Assessment Form - Spanish
Learning Assessment Form - Portuguese
Financial Assistance Application
If you are uninsured, you may qualify for our financial assistance program. Please complete this application to see if you are eligible. If you have questions, please ask to speak with a Certified Application Counselor.
Financial Assistance Application – English
Financial Assistance Application – Spanish
Financial Assistance Application – Portuguese
Parental Consent Form
Parents or guardians, please complete this consent form to allow providers at Lamprey Health Care to provide your child or ward care when you are not present.
Transfer Your
Records to Us
To provide you with the best care possible, our providers need access to your past medical history.
If you have not requested to have your medical records transferred to us, complete this form. Return it to us, and our medical records department will work with your previous provider to transfer the records.
Lamprey Health Care Patient Portal
