Medical Forms / Patient Survey

Below are links to our medical forms and patient satisfaction survey. For your convenience, you may print them out and complete them at  home as needed.

New Patients

Dr. Elizabeth Hicks and Dr. Sergei Shumaster are both accepting new patients by application so please fill out the New Patient Application and submit it to the office. If you use to be established with us with a different doctor but it has been more than 3 years since your last office visit, please fill out the New Patient Application and submit it to the office.

New Patient Forms to Update Your Information

If it has been over a year since your last visit or you are a new patient to the office, please use these forms Adult Health History Form, Patient Information Form, Financial Policy and Notice & Acknowledgment. Please bring these forms, a photo id, and your insurance information to your appointment.

Preparing for Your Visit

Please bring the following items to every visit:

• Current Medications
• Insurance Card
• Photo ID
• List of questions for you to discuss with the doctor
• Forms that need to be completed at your appointment
• Diaries (food, blood pressure readings, blood sugar readings etc.)

Annual Wellness Visit

Family Practice wants you to receive wellness care-healthcare that may lower your risk for illness or injury. The term “physical” is often used to describe wellness healthcare. Unfortunately, Medicare does not pay for a traditional, head-to-toe physical exam. However, Medicare DOES pay for a wellness visit with the wellness nurse once a year to help identify health risks and help you reduce them. We encourage our patients 70 years old and older to have this visit with our wellness nurse each year. Simply contact the office and ask to schedule your wellness visit.

Please complete the Annual Wellness Visit Packet and bring it along with you to your appointment. The document will open in a Word-type document so that it is easy to fill in and print out. If you need assistance, please contact the office and we can guide you through the process.

Authorization to Release Medical Records

In order to obtain a copy of your medical records or want your records sent to another doctor or facility, please fill out the HIPAA Release Form and turn into the office. If you want a personal copy of your medical records there will be a charge. If you need records sent directly to another medical facility, we will send records at no charge.

Authorization to Disclose Information

If you would like the office to disclosure information to someone other than yourself please fill out the Disclosure Authorization form and bring it to the office. Please click on the link to view our Notice of Privacy Policy.