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

virtualconsent-thumb.jpg

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

Registration Form

New Patient Intake Form

New Patient Intake

HIPAA & PAYMENT POLICY

Please click on the forms, print, fill it out and bring it to your initial visit with Lenzmeier Family Medicine.

HIIPA Notice of Privacy

HIPAA Notice of Privacy

Payment Policy

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.

Auth for Release to

Authorization for Release

TO: LFM

Auth for Release From

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 Minor

Treatment of A Minor

(under 18 years of age)

© 2010-2020 Copyright.

All Rights Reserved.
Lenzmeier Family Medicine

20100 N. 51st. Avenue, Ste. F630
Glendale, Arizona 85308

623-376-8000  Office Phone

623-376-8040  Fax Number