PATIENT INFORMATION

The links below will open as PDFs that you can download, read and print. If the document you download is a form, please print it out, fill in the information, as
required, and bring to your appointment at Athens Spine Center.

NEW PATIENT FORMS*

Patient Information
Health History
Medication List
Financial Policy
Acknowledgement Notice of Privacy Practices (Includes Consent for Disclosure to Family)
Controlled Substance Agreement Form**

ALL FORMS

Appointment Reminder
Authorization for Disclosure of PHI (Medical Records RELEASE Form)
Authorization for Disclosure of PHI (Medical Records REQUEST Form)
Acknowledgement of Notice of Privacy Practices
Acknowledgement of Notice of Privacy Practices (Includes Consent for Disclosure to Family)
Consent for Disclosure of PHI to Family/Individuals
Contact Information
Controlled Substance Agreement
Financial Policy
Health History
Medication List
Outpatient Consent for Procedure
Patient Information
Patient Request for Treatment Release

* New Patient Forms. Please download, fill out and bring to your first appointment.
** Please download and print this form and bring with you to your first appointment.
Your signature must be witnessed by clinical staff.