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

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No-Show and Cancellation Policy

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If you need to cancel or reschedule an appointment,

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

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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.

Each time after: A fee of $50 will be incurred each time.

 

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

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Cancellation Policy:
 

Canceling/rescheduling within 48 hours of your appointment time OR arriving more than 15 minutes late, may result in:

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

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

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