Lenzmeier Family Medicine Forms
The forms below are needed for our records. Please take the time to complete the forms before your first appointment with us. You can click on the forms below to open them up. Some forms can be completed right on your computer, or you can print them off and fill them out by hand.
TELEMEDICINE/VIRTUAL CLINIC
Informed Consent for Telemedicine/Virtual Clinic Consultations Form
Prior to a Telemedicine/Virtual Clinic Consultation Visit, this form must be read, completed, signed, and mailed to:
Lenzmeier Family Medicine
20100 N 51st Ave., F630,
Glendale, AZ 85308
Or faxed to 623-376-8040
NEW PATIENT FORMS
These forms can be completed on your computer and filled out with your keyboard.
Please click on the form, complete it online, print and bring it to your initial visit with Lenzmeier Family Medicine.
Registration Form
Phone Communication Preference Form
New Patient Intake
No Show, Late-Cancellation Agreement
HIPAA & PAYMENT POLICY
Please click on the forms, print, fill it out and bring it to your initial visit with Lenzmeier Family Medicine.
HIPAA Notice of Privacy
Payment Policy
AUTHORIZATION FOR RELEASE
For the best and most complete care, there may be times we need to receive as well as share health information with other medical providers.
Authorization for Release
TO: LFM
Authorization for Release
FROM: LFM
TREATMENT OF A MINOR
(under 18 years of age)
This form is for a one-time use when a parent or legal guardian is unable to accompany a minor (under 18 years of age) to the office visit. The parent or legal guardian MUST be available by phone during the scheduled appointment time.
Treatment of A Minor
(under 18 years of age)