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New Patient Information/Forms


Thank you for choosing to become a patient of the Family Practice of Jeffersonville or Jeffersonville Family & Geriatric Medicine. Please contact our office to schedule your first appointment.


In order to save time at your first visit to our office, print and complete the new patient forms (below).


Click here to download a PDF with the Patient Demographics Forms


Click here to download a PDF with the Patient Medical History Forms


Click here to download a PDF with the Financial Policy Form


Click here to download a PDF with the Privacy Practice (HIPAA) Consent Form


Click here to download a PDF with the Record Release Authorization

No-Show and Cancellation Policy

If you need to cancel or reschedule an appointment,

we kindly request at least a 24-hour notice. Thank you.

No-Show Policy:

Failing to show up for an appointment without adequate notice may result in fees or penalties.

First missed appointment No worries, we know things come up!

Second missed appointment: A fee of $25 may be incurred.

Third missed appointment: 3 or more consecutive no-shows in a calendar year may result in dismissal from the practice.

Cancellation Policy:

Canceling/rescheduling within 24 hours of your appointment time OR arriving more than 15 minutes late, may result in:

- Fee for each infraction starting on the third occurrence
- Potential dismissal from the practice

If you incurred a fee due to an unforeseen emergency, please contact our Office Manager to discuss your situation further.

Scheduling an Appointment:


Patients are seen by appointment only. You may schedule appointments during office hours on Monday-Friday by contacting our office at (610) 277-9040. 


We truly believe that your time is valuable and make every effort to stay on schedule. However, on some occasions, certain medical situations or emergencies will take precedence. We ask for your understanding in these situations. Similarly, if you should need to cancel an appointment, please call us at least 24 hours in advance.

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