New Patient Information and Registration Forms

All new patients should bring the following three forms, completed, to your first appointment.

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Financial Policy Form

In order to reduce misunderstandings, we have adopted the Financial Policy outlined on this form. We require that you read it carefully, initial each numbered section in the space provided, and sign at the bottom prior to the start of any treatment.
Download Form

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Patient Registration Form

The Patient Registration Form includes basic information about the patient for our records.
Download Form

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Medical History Form

This form helps our physicians understand your medical history and best assess your needs.
Adult - 18 and older
Adolescent - 10 to 18
Child - 10 and younger

Other Forms

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Consent to Treat a Minor

A parent or legal guardian is required to accompany a minor child (age 17 or younger) on the first visit. If you would like to give consent for your minor child to be seen in the absence of a parent or guardian on subsequent visits, sign and send the following form with them:
Download Form

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Release of Records To Kachina Family Practice

Use this form to request your medical records be sent from another provider to Kachina Family Practice:
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Release of Records From Kachina Family Practice

Use this form to request your medical records be sent from Kachina Family Practice to another provider, an Insurance company, or other party/institution:
Records Release Form

Please Note: There is no charge for records sent directly to another provider; however, other records transfers may require a fee.