New Patients

Before your first appointment, please fill out the paperwork below. Provide as much detail as possible to ensure we have a
complete picture of your health history and are aware of any concerns that could affect your care. You can return these forms
during your first visit.

new-patients-top

Intake History

To make appropriate health recommendations, we need some information about your past medical history and current use of medications. Please fill out this form with as much detail as possible to ensure we have the information needed to develop a comprehensive treatment plan.

Use and Disclosure of Personal Health

This form discusses our privacy practices and authorizes us to share certain information for treatment and/or billing purposes.

Patient Registration Form

It's important that we have your current contact information and insurance details on file. Please provide your name, address, telephone number, and billing information on this form.

Patient Authorization Record

The Patient Authorization Record indicates that we have your permission to treat you and bill you for the services we provide. It also contains details about billing and assignment of benefits.

Payment and Collection Policy

Summit Medical's Payment and Collection Policy summarizes our financial policies and provides details about our payment plans to obstetrical and surgical patients.