Forms  I  Info

INFORMATION & FORMS

What you need to bring to your first appointment:

  • Your medical records
  • A list of your current prescriptions
  • Your insurance information
  • Vaccine records

Patient Forms

In order to make your appointment as time-efficient and stress-free as possible, please download, print and fill out any of the following applicable forms prior to your appointment date.

REQUIRED—All New Patients
Patient Registration Information
Health History


Practice Policy
Financial Policy
Privacy Practices
Receipt of Notice of Privacy Practices

RELEASES—If Needed
Authorization for Release of Medical Records from Another Doctor to Dr. Waneka
Authorization for Release of Medical Records from Dr. Waneka to Another Doctor
Authorization for Treatment of a Minor
Psychiatry Release

Patients who need a TB Screen:

Tuberculosis (TB) Screening



Patients who need Flu Shots:

Influenza Vaccine Consent