866-228-2236

SAFE and SECURE Online Submission

For your convenience, the following forms may be submitted online UP TO 2 DAYS prior to your first appointment, then transmitted SAFELY and SECURELY to our Patient Registration Desk. To complete the form simply click on the link below:

Adult Registration Packet – ONLINE SUBMISSION*
Pediatric Registration Packet – ONLINE SUBMISSION*

*Please allow 2 working days for processing

Paper Submission

Note: The forms below that are marked as “Fillable” may be completed manually or on your computer, then printed and brought to your doctor’s office. To complete a form using your computer:

  1. Double-click on the form you need and save it to your computer or device.
  2. Type your answer(s) in each field. (Save your work often.)
  3. Print the completed form(s) on your home or office printer.
  4. Sign where indicated.
  5. Bring the completed form(s) with you to your next appointment or submit them as indicated.

Adult  Registration Packet – FILLABLE (.pdf, 1MB)
Pediatric Registration Packet – FILLABLE (.pdf, 751 KB)
Patient Financial Agreement – English – FILLABLE (.pdf, 169 KB)
Routine Preventive Exam – English Spanish – FILLABLE (.pdf, 193 KB)
Notice of Privacy Practices (.pdf, 96 KB)
Medical Records Release to Graybill – FILLABLE (.pdf, 386 KB)
Medical Records Release to Other Provider – FILLABLE(.pdf, 174 KB)
NextGen Patient Proxy – English Spanish – FILLABLE
Preparticipation Physical Exam – History (.pdf, 148 KB)

Formas De La Lengua Espanola

Por su conveniencia, los formularios marcados “Llenar” pueden completarse manualmente o en su computadora. Para completer en su computadora:

  1. Escriba su respuesta a cada pregunta en el formulario.
  2. Guarde su formulario en www.graybill.org su computadora o dispositivo.
  3. Imprima su formulario completo y llévelo a su primara cita.

Registro del Paciente Adulto – LLENAR (.pdf 2.2 MB)
Registro del Paciente Pediátrico – LLENAR (.pdf, 751 KB)
Exámenes Preventivos de Rutina – LLENAR (.pdf, 193 KB)
Acuerdo Financiero del Paciente – LLENAR (.pdf, 170 KB)
Aviso de Prácticas de Privacidad 0415 (.pdf, 165 KB)
Autorización Para Revelar El Registro Médico 0616 – LLENAR (.pdf, 1MB)
Autorización Para Revelar El Registro Medico al Otro Proveedor 0516 (.pdf, 1MB)
Los Padres/Tutor Legal Para Acceder a Peticiondel Paciente Menor NextGen Cuenta de Portal – LLENAR (.pdf, 540 KB)

Menu