Intake Forms & Updates

NEW PATIENT FORMS

FIRST! Please download forms, below, to your computer, save and THEN complete. If you open forms below and just start filling them out you will lose all your data and we will receive BLANK forms when you send them to us.
We ask that you return these forms at least 24 hour prior to your visit and be sure that you have a confirmation from us that we have received them. It is best to use Google Chrome when downloading forms.
If you have an Apple Computer, go to this article for help or you will need to download forms, PRINT them, and then fax them to us at 866-644-6363, or scan and email them to us at office@breakthroughmed.com.
PLEASE BE AWARE THAT IF YOU ARE A NEW PATIENT AND WE DO NOT RECEIVE A FULLY COMPLETE HISTORY INTAKE AND CONTACT INFORMATION FORMS WITHIN 24 HOURS OF YOUR APPOINTMENT, YOU MAY NEED TO RE-SCHEDULE.

Female History Intake or Male History Intake

Contact Information

Release of Records

Notice of Privacy Practices

Acknowledgement of Receipt of Privacy Practices

Letter of Understanding ERX

Informed Consent

Physician/Patient Arbitration Agreement

Credit Card Authorization Form

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RETURN UPDATE FORMS

Female Return Update

Male Return Update

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EMERGENCY REFILL FORMS

Emergency Refill Form

ERX Update – Female

ERX Update – Male