Patient Forms

All forms are in Adobe PDF format and require a PDF viewer to open and print the forms.

New Patients to KDC

If you are a new patient to KDC we will need the following forms filled out for your appointment:

• Registration Form
• HIPPA Form

Established King's Daughters Clinic Patients

Established patients at King’s Daughters Clinic will need to fill out these forms at the following intervals:

• Registration-Every calendar year
• Medical History (Adult or Pediatrics for your Primary Care Provider)-Every two (2) years
• HIPPA-Every seven (7) years

Department Forms

If you are seeing a doctor in Primary Care Provider for the first time(Family Practice, Pediatrics or Internal Medicine), you will also need to fill out:

• Adult Health History Form if you are 19 years of age or older
• Pediatric Health History Form if you are UNDER 19 years of age

If you are seeing a Specialty Physician (any provider other than Family Practice, Pediatrics or Internal Medicine) for the first time, you will need to fill out their specific Health History Form:

Allergy

• Allergy Questionaire
• Allergy Health History Form

Eye Center

• Eye Center Patient History Form for all patients seen at the Eye Center
• Eye Center Insurance Update Form for all patients seen at the Eye Center
• Eye Center Refraction Policy Form for all patients seen at the Eye Center

Gastroenterology

• Gastroenterology Personal Medical History Form

Neurology

• Neurology Health History Form for all patients seeing Neurologist
• Neurology Headache History Form for all patients seeing the Neurologist for headaches

Otolaryngology (Ear, Nose and Throat)

• Otolaryngology Pediatric Form (if under 18)
• Otolaryngology Adult Health History Form (if 19 or over)

Podiatry

• Podiatry New Patient Consult Form

Women's Center

• Women's Center Personal Medical History Form for all patients seen at the Women's Center
• Heredity Cancer Screening for all patients seen at the Women's Center
• HIV Consent Form

Medical Records

• Release of Information