New Patient Info
Location/Map & Hours
These forms are in PDF format and can be opened with Adobe Reader. You can click here to download Adobe Reader.
New Patient Information and Registration Forms
All new patients should bring the following three forms, completed, to your first appointment.
Patient Registration Form
Medical History Forms:
Adult, 18 and older
Child, 10 and younger
If your child, 17 and younger, will be seen in the absence of a parent
or guardian, sign and send the following form with them:
Consent to Treat a Minor
To request your medical records be sent from another provider to
Kachina Family Practice:
Release of Records to Kachina Family Practice
To request your medical records be sent from Kachina Family Practice to
another provider, or an Insurance company, or for any other reason:
Release of Records From Kachina Family Practice
(There is no charge for records sent directly to
another provider, however, other records transfers may require a fee).
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16611 S 40th Street, Suite 120, Phoenix, Arizona 85048
All rights reserved.