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:
- Double-click on the form you need and save it to your computer or device.
- Type your answer(s) in each field. (Save your work often.)
- Print the completed form(s) on your home or office printer.
- Sign where indicated.
- 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:
- Escriba su respuesta a cada pregunta en el formulario.
- Guarde su formulario en www.graybill.org su computadora o dispositivo.
- 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 – LLENAR (.pdf, 1MB)
Autorización Para Revelar El Registro Medico al Otro Proveedor (.pdf, 1MB)
Los Padres/Tutor Legal Para Acceder a Peticiondel Paciente Menor NextGen Cuenta de Portal – LLENAR (.pdf, 540 KB)