New Patient Forms

We know your time is valuable, so we have posted our new-patient forms online to fill out before you arrive at our office. There will be additional questions to answer upon arrival at our office, so if a new patient, please arrive at least 25 minutes prior to your appointment time. Existing patients should arrive at least 10 minutes prior to their scheduled appointment.

Just print and complete all relevant forms and bring them with you to the DiabeVita office. Please bring your photo ID and insurance card(s) as well if applicable. We’ll scan them into our electronic medical records system.

All forms below are in PDF format, which your computer should recognize. We can also fax or email forms to you if more convenient. Click on each form name in blue to see the form on your screen.

Patient Registration, Insurance and Medical History Forms

This form is required of all new patients. Here you’ll give us information on you and your family members, emergency contacts, and any insurance company you want us to work with. This is also where you can tell us about any allergies, existing physical conditions, current medicines, etc so we can better treat you for future optimum health.

Financial Policy and Acknowledgement Forms

Many health care decisions come with financial implications. These forms explain our policies on billing, payments, and terms of service, and serve as a checklist for information we'll give you when you arrive. We will gladly answer any questions you may have after reviewing this information.

Medical Records Request and Pharmacy Access Authorization Forms

Please print and sign page 1 of this form to give us access to certain electronic pharmaceutical records maintained by your insurance company and pharmacy.

If you would like us to have a copy of your medical records from another doctor or hospital office, complete the second page of this 3-page form and send to that doctor’s office. Note there may be a small charge to you by that doctor’s office for retrieving your records, copying and then sending to us.

If you need a copy of your record from our office to give to another doctor, complete the last page of this 3-page form and we can send it by mail, through a secure electronic connection or provide you with a copy. There may be a small charge for our time. You can obtain parts of your medical record at no cost anytime from our secure and confidential Patient Portal.

HIPAA Privacy Policies

We adhere to all records privacy rules and regulation as set forth by the Health Insurance Portability and Accountability Act (HIPAA) and other applicable laws. This explains what we will or will not do with any personal health information we obtain arising from our physician-patient relationship. We need to know the names of anyone you wish to identify as authorized recipients of your health information.