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Save time by printing and filling out our patient forms before you arrive for your appointment.
- Patient Information Form
- Payment Authorization Form
- Patient History
- Medication List
- Medical Release Authorization
- Medical Power of Attorney
- Acknowledgement of Receipt of Privacy Practices
As our patient…
You have a right to dignity, respect, and consideration of legitimate concerns.
You have the right to privacy and confidentiality.
You have the right to information about the current diagnosis, treatment, and prognosis. If it is not medically advisable to give such information to you, the patient, it should be available to an appropriate custodian.
You have the right to refuse any diagnostic treatment or procedure, and to be advised of the medical consequences of such refusal.
You have the right to participate in the decision involving your care, unless this participation is not indicated for medical reasons.
You have a right to know who will be delivering your care.
You have the right to change your physician if another qualified practitioner is available.
You have the right to inspect and obtain a copy of your medical records. In addition, the patient has the right to expect reasonable and timely transfer of information from one physician to another.
You have the right to request information concerning the bill for services regardless of the source of payment.
You have the right to be assured that the proposed care will be delivered in a timely, efficient, and cost-effective manner and that the expected results can be reasonably anticipated.
You have the right to expect materials promoting The Urological Center to be accurate and forthright.
You have the right to request information about alternative sources of qualified care.
You have the right to know that The Urological Center expects certain standards of patient conduct and responsibility and that failure to comply may have consequences for your care.