Form

Walnut Creek Surgical Associates

General, Laparoscopic, and Trauma Surgeons

Patient Forms (3 Forms)

Michael S. Baker, MD, FACS ~ J. Norris Childs, MD, FACS ~ Peter J. Mazolewski, MD, FACS

Monica S. Eigelberger, MD, FACS ~ Steven M. Young, MD, FACS ~ Charleen K. Lee, MD

General, Laparoscopic, and Trauma Surgeons

All downloadable files are in PDF format. PDF documents retain the original formatting regardless of computer platform or Internet browser.

To view and print PDF files, you will need Acrobat^® Reader^®. You may already have it installed. If not, you can download it directly from Adobe^® by clicking on the icon below.

FORM 2: MEDICAL INFORMATION FORM Instructions:
1.	Click on the miniature form with the PDF logo. Acrobat^® Reader^® will load it into the browser.
2.	Print the form and complete it prior to your appointment. You may fill out the form directly on your computer and print it out. Filled out forms cannot be saved or emailed from your computer.
3.	Present the completed form to our front office staff at your surgical appointment. This form should be updated every 6 months.

FORM 1: REGISTRATION FORM Instructions:
1.	Click on the miniature form with the PDF logo. Acrobat^® Reader^® will load it into the browser.
2.	Print the form and complete it prior to your appointment. You may fill out the form directly on your computer and print it out. Filled out forms cannot be saved or emailed from your computer.
3.	Present the completed form to our front office staff at your surgical appointment.

Description:

The Patient Information form must be completed by all new patients. If you are an existing patient, you do not need to update this form unless your last visit to our office has been over one year.

Completing this form prior to your appointment will alleviate the need to complete it at our office. This will help us better serve you and provide us with more time to provide excellent surgical care.

FORM 3: NOTICE OF PRIVACY PRACTICES Instructions:
1.	Click on the miniature form with the PDF logo. Acrobat^® Reader^® will load it into the browser.
2.	This form outlines the uses or disclosures of your health information by law. Please print and read prior to your visit with us. On arrival, you will be asked to sign an acknowledgment of receipt of this form.

Please Note: We DO accept Visa and Mastercard for payments. We do not take AMEX.

FORM 4: CONFIDENTIAL COMMUNICATION PREFERENCE Instructions:
1.	Click on the miniature form with the PDF logo. Acrobat^® Reader^® will load it into the browser.
2.	Print the form and complete it prior to your appointment. You may fill out the form directly on your computer and print it out. Filled out forms cannot be saved or emailed from your computer. We value your privacy, and we need to know how to communicate information with you and your family.