Patient Forms

Patient Intake Form: :

What to Bring to your appointment:

• All necessary referrals – you must contact your insurance company to determine if a referral is needed
• A list of all your medical problems and previous surgeries
• A current detailed list of your medications
• List of any allergies
• Any previous medical records pertaining to your condition (i.e. – Emergency Room records, X-rays, Lab tests, previous urologist’s notes, previous operative reports, etc )

“New Patient Form"

Medical Records Requests:

"AUTHORIZATION TO RELEASE MEDICAL RECORDS TO THIRD PERSON RELATIVE, FRIEND, ETC."  

"REQUEST TO RELEASE MEDICAL RECORDS TO PATIENT"

"REQUEST TO RELEASE MEDICAL RECORDS TO PREMIER UROLOGY GROUP"

"REQUEST TO RELEASE MEDICAL RECORDS TO PHYSICIAN OUTSIDE OF THE GROUP

Office Procedures:

CYSTOSCOPY CONSENT

PROSTATE BIOPSY CONSENT

PROSTATE BIOPSY PREPARATION INSTRUCTIONS

PROSTATE BIOPSY POST-OP INSTRUCTIONS

PROSTATE BIOPSY CONSENT IN SPANISH

PROSTATE BIOPSY PREPARATION INSTRUCTIONS IN SPANISH.

PROSTATE BIOPSY POST-OP INSTRUCTIONS IN SPANISH.

VASECTOMY CONSENT

VASECTOMY POST OP INSTRUCTIONS

General Office Information:

FINANCIAL DISCLOSURE

INSURANCE PARTICIPATION LIST

PRIVACY POLICIES

PRIVACY PRACTICES

OFFICE PROCEDURES