Instructions for Using the Forms
New Patient
If this is your first appointment with the doctor, please fill out and sign each of the forms under the New Patient Intake Forms section. Otherwise please fill out the forms that the doctor's office specifies for you.
Exiting Patient
Existing patient: please fill out the forms that the doctor's office specifies for you.
Submitting the forms
For tele-health visit, please return the completed forms to the doctor's office by fax before the scheduled date of visit. The doctor's office does not accept forms via unsecured emails or text messages. For in-person visit, you can fax the completed forms, or bring them with you, to the doctor's office.
If you are an existing Patient Ally user, you can complete the forms from within the Patient Ally Portal
New Patient Intake Forms
| # | Form | English | Chinese |
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1 |
General Consent Form |
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2 |
Patient Consent Form |
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3 |
Patient Rights and Responsibilities |
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4 |
Patient Information Form |
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5 |
Health History Form |
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6 |
Medication Form |
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Other Forms
| # | Form | English | Chinese |
|---|---|---|---|
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7 |
Patient Health Care Questionnaire |
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8 |
Annual Wellness Visit Form |
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9 |
Health Risk and Preventive Care Assessment Form |
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10 |
Health Risk and Preventive Care Assessment for Ages 50 and Over |
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11 |
Systemic Review Form |
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12 |
Stay Health Assessment Form for Adult |
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13 |
Stay Health Assessment Form for Senior |