Forms
Depending on your sex, age and who you are seeing in our practice, please fill out the forms as listed below.
Remember that you need to be at our office 15 minutes prior to your scheduled appointment time to register if you are new to our office. Please bring your insurance card with you. If you have a co-pay or payment due, this will be collected prior to your visit.
New Patient Child ages 2-12
**If someone other than the parent/guardian will bring the child to the office, you will need to complete the Consent for Authorization for Treatment of a Minor naming that person as the parents’ representative.
New Patient Adolescent ages 13-17
- Teen New Patient Packet
- HIPAA Signature Page signed by teen (if you want your parents to have access to your records, please list their names on the form)
- Records Release TO Sonoran Medical Centers from another provider
**If you come to the office without a parent/guardian, you will need to have your parent/guardian complete and sign the Consent to Treat a Minor form
**If you come to the office with an adult other than your parent/guardian, you will need to have your parent/guardian complete the Consent for Authorization for Treatment of a Minor
New Patient Adult 18 to 64
- Adult New Patient Packet
- Records Release TO Sonoran Medical Centers from another provider
- If seeing Dr Gronski and have Diabetes also add this
New Patient Adult 65 and older
- Geriatric New Patient Packet
- Records Release TO Sonoran Medical Centers from another provider
- If seeing Dr Gronski and have Diabetes also add this
New Patient Female seeing Dr. Belen for Gynecology
Misc Forms
- Mental Health Evaluation
- Complaint Form
- Patient Medication Log
- Records Release FROM Sonoran Medical Centers to another party
- Records Release FROM Sonoran Medical Centers to patient
- Records Release TO Sonoran Medical Centers from another party
- Notice of Privacy Practices (HIPAA)
- HIPAA Signature Page signed by patient (if you want someone else to have access to your records, please list their names on the form)
- Arizona Health Information Exchange Notice of Health Information Practices
- Arizona Health Information Exchange opt out form
- Arizona Health Information Exchange Information
- Arizona Health Information Exchange Information from Az.Gov