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PATIENT FORMS



New Patient Forms

Please click on the New Patient Packet Form below.  You can either fill out online and print or you can print a blank copy and fill it out. Please bring the completed packet to your first appointment.  There is additional information you need to provide via our EMR (Electronic Medical Record), so please arrive 15 minutes early.

Note:  If you do not have your new patient packet (to the right) filled out prior to your appointment, please arrive 30 minutes early to ensure we have all the necessary information to provide you with the best care possible.


Medical Record Request Form

If you would like Your Health District to receive your medical records from another practice, please click on and print the Medical Record Request form below. Please send the completed form it to the practice so they can send Your Health District your medical records.


NEW PATIENT PACKET FORMS
MEDICAL RECORD RELEASE REQUEST FORM
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Anthem Chamber of Commerce

Contact Us

Phone –

(623) 748-9106

Fax –

(602) 429-8579

Address –

2525 W Carefree Hwy, Bldg 3, Suite 118
Phoenix, AZ 85085

Email –

Info@YourHealthDistrict.com

 

Copyright by Your Health District 2019. All rights reserved.