Healthcare Practice 'Providing High Quality Cost-Effective Healthcare To All'
Adolescent/Adult Medical History Information
Please take a moment to complete the 'Health Screening' form listed below as requested by our healthcare practice:
Advanced Health Care Directive
When properly integrated with a corporate wellness plan, screenings can help reduce health risks, improve health status, reduce health care costs, and improve productivity and performance of the workforce.
Tetanus & Diphtheria Vaccine
Pediatric Medical History Information
New Patient Information
Consent For Tuberculin Skin Test
Influenza Vaccine Consent Form
Generalized Anxiety Disorder
Authorization to Leave Health Information by Alternate Means
Acknowledgement of Notice of Receipt of Privacy Policies
Member Services Guide
Clinic Financial, Payment & Other Policies
Authorization for Provider to Release Health Plan Information
Patient Registration and Insurance Assignment
Authorization to Disclose/Release Protected Health Information
DR. NLGD LLC Healthcare Practice
1660 South Alma School Road ▪ Suite 125
Mesa, AZ 85210
P 480.669.6452 ▪ F 888.977.3601
LEGAL - PRIVACY l COPYRIGHT © 2017 - 2018 l DR. NLGD LLC. ALL RIGHTS RESERVED.
Medical Appointment Cancellation Policy