Forms

For your convenience, San Rafael Medical Center has made the following forms available online. Please print and fill out all applicable forms and present them at the reception desk upon arrival. If you are a new patient visiting our office for the first time, please complete the following forms to provide our doctors with all the information they need, and to ensure sufficient time to address all your concerns:

  1. Print and complete the Registration Form.
  2. Print and complete the Health History Questionnaire. Your previous medical history, current medications, and allergies will help our physicians establish the most appropriate plan of care for you.
  3. Print and complete the Financial Policy.
  4. Print and complete our Medication Policy.
  5. Review our Privacy Policy and print and complete the Acknowledgement of Privacy Practices.
  6. Print and complete the Medical Records Release Request. This will allow our team to request records from your previous physician(s) so our physicians can have a comprehensive understanding of your past medical history. Please note, if you have more than one physician who you would like to request records from, a separate release is required for each physician.