Forms

This page includes downloadable documents for the convenience of the patient.

New Patient Forms (Required at your first visit)

These forms are required to be filled out at your first visit.  They include a “Consent to Treat”, “HIPPA medical release”, “Health summary” and “Transfer of Prior Medical Records”. Please complete these forms prior to your first visit.  Doing so will allow more time to spend with your medical provider discussing your specific health needs.

Download New Patient Forms

Transfer of Medical Records

If you need to request a transfer of medical records from your previous medical provider, please complete this form and fax or mail to them.  You can also complete this form and bring it into the office and we can fax it for you.  It can take up to 30 days depending on your previous medical providers response time.

Download Transfer of Medical Records

Questionnaire for Weight Loss Program (First Visit)

Please take a moment to fill out this form prior to your first weight loss visit.  You may print and bring in completed form to your first visit or email a completed copy to Dr. Quigley’s nurse, Meagan at mfitzpatrick@peakhealthmedicine.com prior to coming in.

Download Weight Loss Program Questionnaire

Notice of Privacy Practices – HIPAA

In 1996, the Health Insurance Portability and Accountability Act or the HIPAA was endorsed by the U.S. Congress.  The HIPAA Privacy Rule, also called the Standards for Privacy of Individually Identifiable Health Information, provided the first nationally-recognizable regulations for the use/disclosure of an individual’s health information.  This document outlines those regulations.

Download Notice of Privacy Practices