Forms

You may print out the forms below to bring with you to your appointment. Please fill the forms out completely and accurately.

New Patient

• New Patient Packet


• New Patient Packet - Pediatric - Dr Greene Only

New Injury

• History Form (Adults and all pediatric patient's except Dr. Greene's)


• Pediatric Health Form (Dr. Greene's Patients Only)

Other

• Notice of Privacy Practices


• Authorization to Release Protected Health Information


• Authorization to Treat a Minor

Medical Records

A copy of your medical records and/or X-ray films is available upon your written request. You should complete an Authorization to Release Protected Health Information form to request such copies. We do charge a fee for medical record and X-ray copies and may ask for prepayment of the fee. Please allow us 5-7 business days to complete your request. For more information contact our Medical Secretary at (910) 484-2171 ext. 101.

Completion of Forms

Forms that need to be completed by your provider may be turned in to the Medical Secretary or at the front desk. We do charge a nominal fee (per form) to complete forms and require all fees to be paid at the time the form is dropped off for completion. Please allow us 48-72 hours to complete your form.