Patient Information and Registration Forms

All new patients should bring the following four forms, completed, to your first appointment. Or if you are an existing patient but haven’t been seen in the last 3 years, please complete the four forms and bring to your next appointment so we can update our records.

Patient Welcome Form

The Patient Welcome Form provides a introduction to the clinic. 

Patient Welcome Letter

Patient Registration Form

The Patient Registration Form Includes basic information about the patient for our records. 

Patient Registration
Download Controlled Substance Form
Download Code of Conduct Form

Medical History Form

This form helps our providers understand your medical history and best assess your needs. Complete the version that corresponds to your age.

In order to reduce misunderstandings, we have adopted the Financial Policy outlined on this form. We require that you read it carefully, initial each numbered section in the space provided, and sign at the bottom prior to the start of any treatment.

Download Form

HIPAA / Privacy Policy

Our privacy policy aims to protect your personal information and is compliant with the HIPAA Privacy Rule. Please review the policy, and sign to affirm you have read and understand the policy. If you wish to authorize us to share your information with another person, please complete the optional Release of Information section at the end.

Download Form

Other Forms

Consent to Treat a Minor

A parent or legal guardian is required to accompany a minor child (age 17 or younger) on the first visit. If you would like to give consent for your minor child to be seen in the absence of a parent or guardian on subsequent visits, sign and send the following form with them:

Download Form

Release of Records TO Canyon Family Medicine

Use this form to request your medical records be sent from another provider to Canyon Family Medicine:

Download Form

Release of Records FROM Canyon Family Medicine

Use this form to request your medical records be sent from Canyon Family Medicine to another provider, an Insurance company, or another party/institution:

Download Form

Please Note: There is no charge for records sent directly to another provider; however, other records transfers may require a fee.

Whether you’re suffering from an injury or illness, we’ve got you covered.


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