:: Forms

If you would like to save time at registration, you may download forms and fill them out before you get here.

New Patients
If you are a new patient or if you are coming in for a new injury or illness, you will need the following forms:

Medical History Survey [pdf]

Medication List [pdf]

Financial Policy [pdf]

Sports Physicals
If you are coming in for a sports physical, fill out the forms above and the sports physical form below:

Sports Physical Survey [pdf]

Nutrition Consultation
If you are coming in for a nutrition consultation and you were told that you needed the 3-Day Diet Record, please fill this record out and fax it back at least 5 days prior to your appointment time.  You will also need to fill out the New Patient Forms above.

3 Day Diet Record [pdf]

Beverage Portions [pdf]

Estimating Portion Sizes [pdf]

Portion Sizes Card [pdf]

EKG Waiver Form
If you are participating in one of our indoor cycling classes and you are a male who is 45+ or a female who is 55+, you will need to schedule an EKG at BCSM or you will need to have a physician sign the EKG waiver below.  You will not be allowed to participate without it. 

EKG Waiver [pdf]

Medical Records Release
If you would like to have a copy of your medical records, or if you would like to release your records to another medical office or someone other than yourself, you must fill out the medical release form below.  Please allow 30 days for records to be released.

Medical Records Release [pdf]

 

 

 

 

 

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