New Patient Forms

Welcome From Thomas F. Carmen, M.D. & Associates

Thank you for choosing Thomas F. Carmen, M.D. & Associates for your health care. Please know that our doctors, nurses and administrators value the trust you have placed in us and will do all they can to meet your expectations for quality medical care.

What to Bring to Your First Visit

We believe that the patient-doctor relationship is integral in keeping our patients healthy.

Our physicians want to make your first visit with us a success and are interested in learning as much as possible about your current health status.

Filling out these forms (available below) will help your physician make the most of your time together.

If you are insured, the office staff will ask to see your insurance card.

New Patient Intake Form (For All New Patients)

All new patients are asked to fill out a New Patient Intake Form, so our Doctors can better prepare for your specialized care.

Authorization to Release Medical Records Form (For Transferring Patients)

All new patients who are transferring from another medical practice are asked to fill out an Authorization to Release Medical Records Form, so our Doctors can access your prior health records.

Senior Health Questionnaire (For Seniors Over Age 65)

All new senior patients age 65 or older are asked to fill out a Senior Health Questionnaire Form, so our Doctors can better prepare for your specialized care.

My Medicine List Form (For All Patients)

My Medicine List – This form helps you and your family members remember all of the medicines you are taking. Take this form with you on all visits to your clinic, pharmacy, hospital, physician, or other providers. More detailed directions are included on the form.

Advance Directive Declaration (For Seniors Over Age 65)

All new senior patients age 65 or older are asked to fill out an Advance Directive Declaration Form, so our Doctors can administer specialized care should you become incompetent.

Please print out the appropriate forms (below) at home prior to your appointment, fill them out, and bring them with you. If you do not have these forms completed upon your first office visit you will be provided with a blank copies and asked to complete them in the waiting room prior to seeing the Doctor.


Document Name PDF Format

New Patient Intake Form
(For All New Patients)

Health Information Authorization Form
(For Transferring Patients)

Senior Health Questionnaire Form
(For Seniors Over Age 65)

My Medicine List Form
(For All Patients)

Advanced Directives Form
(For Seniors Over Age 65)

Advanced Directives Brochure
(For Seniors Over Age 65)

If for some reason you are unable to open a PDF file a hard copy will be available in the office prior to your appointment.

• For our physicians to treat you most effectively, we will ask you to fill out a patient information questionnaire at your first visit. Please bring information about past and current medical treatments and illnesses you have had, including approximate dates.

• Know if you have met your insurance company’s deductible. If you are not sure, call your insurance company. A toll-free number will be on your insurance card.

• If you are a Medicare patient, remember there is an annual deductible that must be met.

• You will be responsible for the amount of co-payment at the time of treatment. We accept cash, checks, debit/credit cards (MasterCard/Visa).

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