Forms

ATTENTION: Please take special note of your appointment location when you receive your appointment reminder call.

---

New Patient Forms

For your first appointment, patients must bring the New Patient Registration Forms AND the New Patient Medical History/Intake Form for the physician they are seeing.

   1. ALL PATIENTS: Print out and complete New Patient Registration Forms (4 pages)

   2. Dr. Feuer’s Patients Only: Print out and complete New Patient Medical History/Intake Form (6 pages)

   3. Dr. Glasgow’s Patients Only: Print out and complete New Patient Medical History/Intake Form (5 pages)

You will need to bring to your first appointment, the following:

• Completed New Patient Registration Forms


• Completed Medical History/Intake Forms


• List of all your current prescriptions and over-the-counter medications


• Medical insurance card


• Photo ID

If you are unable to print or need assistance with the forms, we ask that you please arrive at our office 30

minutes prior to your scheduled appointment time.

Existing Patient Forms

We request that you please download and complete the Registration Form below if any of the following applies

to you:

• Your appointment will be your first one this calendar year


• You have had a change in address, phone number, or medical insurance since your last visit

Registration Form

Optional Forms

Medical Records Release Form

Consent to Communicate with Designated Individuals Form (Optional)

If you would like your spouse, family members or other caregivers to communicate verbally with AGO

about your care and treatment, please complete this form below.


Consent to Communicate With Designated Individuals Form

Additional References (optional printing for your records)

• Patient Rights & Responsibilities

• HIPAA Notice of Privacy Practices

• Partnership for Safety Information Guide