Forms

Online Patient Enrollment

You can get on the waiting list for membership of Your Personal MD by completing an online enrollment form. The enrollment process will take about 15 minutes. You'll be asked some general questions about your health status and history. A credit card number will be required to complete your enrollment. You can also enroll in person in the office.

Member Agreements

The member agreement describes how membership works in detail, the kinds of services that are covered, and the kinds of services that are not covered. I am happy to answer any questions. If you decide to become a member, I'll need a signed copy of this agreement.

Download the Membership Agreement

 

Release of Medical Information

From time to time it may be necessary for us to receive information about you from other medical facilities. If you need to complete this form, we'll let you know.

Download the Release of Information form

 

Privacy Policy

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.  We need a signed copy from each patient.

Download the Privacy Policy