Santa Cruz DPC Patient Forms
Membership Contract
This is our contract to become a member of our practice.
Patient History
Tell us about yourself and your history. Please fill out this form to detail your medical history.
Information and Billing
Please fill out this form with your personal information as well as billing information.
Medical Records Release
Please fill out this form to allow us to request your medical history from prior or existing medical providers.
Medicare Patients
Please fill out this form if you are covered or eligible for Medicare.
Privacy Notice
This is our “Notice of Patient Privacy Practices”. Please read this notice carefully as it details how medical information may be used, disclosed and how you can get access to this information.