Pierre A. Lemaire MD, P.A.
General, Vascular and Thoracic Surgery
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Forms for new patients

Patient registration can take 15-30 minutes before seeing the physician on your first visit.   Please print and fill out each document below and bring with you to your appointment.  Instructions are to the right of each form.  ( NOTE: Press the "Back" button on the toolbar to come back to this screen to print each document.)
Patient Registration - Fill out completely
Patient Medical History - Fill out completely

 Acknowledgement of Notice of Privacy Practice - Fill out completely

Our "Notice of Privacy Practice"

Authorization to Release Medical Records from other Facilities or Healthcare Providers - Fill out Patient section at top and sign at the bottom.

Authorization to Release Medical Records to other Facilities or Healthcare Providers - Fill out only the Patient section at the bottom half of the form and sign.
 Financial Policy - Sign and date.
 Assignment of Benefits Sign and date.