Patient Forms
For your convenience, the forms below can be printed out and completed prior to your visit. Bring them with you to your appointment to facilitate the check-in process.
Please fill out all of the forms at right and bring them into the office when you arrive for your appointment. Additional IGO Medical information, including a map, is also available.
New patient appointments are scheduled in advance so our physicians have a chance to get to know patients and their concerns and can make the most of their time. If you decide not to keep your appointment with a IGO Medical physician, please call at least one business day in advance so we can schedule another patient instead.
New Patient Forms:
Forms to complete prior to your new patient visit:
- New Patient Registration Form
- New Patient Medical History Form
- HIPAA Form
- Patient Acceptance of Financial Responsibility Form
Information on IGO for your review:
Established Patient Forms
IGO Medical has a new Electronic Health Record system called Epic. In order to populate the new system with your health and demographic information, we ask that you complete the following forms in advance and bring them on the day of your visit.
Please arrive 30 minutes prior to your appointment so we can update our system with your information. We appreciate your patience as we transition to Epic.
Established Patient Forms
HIPAA Form
Update your Health Information Privacy Information by completing this form. Bring it into the office or fax it to (858) 455-6816.
Women’s Awareness Calendar
Complete this form to assess your hormonal status. Bring this completed form to your appointment. Your physician will review the results with you.
Request for Release of Protected Health Information
(if providing IGO Medical with records from elsewhere)
Please fill out this form and give it to your healthcare providers. They will send your records to IGO Medical.
Request for Release of Protected Health Information
(if having IGO Medical send records elsewhere)
Please fill out this form and bring it into the office or fax it to (858) 455-6816. We will have your requested records copied and mailed per your instructions.
Request for Release of Breast Imaging Records and Reports
(If providing IGO Medical with records from elsewhere)
Please fill out this form and give it to your healthcare providers. They will send your records to IGO Medical Group.