Please download and complete the relevant form(s) below, then send them to us securely through your patient portal account or through our HIPAA-compliant confidential email.
AUTHORIZATION TO RELEASE HEALTH CARE INFORMATION
This form is required if you would like records released from or to your doctor.
This form is required if you would like records released from or to your doctor.
| snm_recordsrelease2022.pdf |
CLINIC POLICIES FORM
This form is required for all new patients. It can be viewed and signed in your Charm patient portal account.
This form is required for all new patients. It can be viewed and signed in your Charm patient portal account.
| clinic_policies_stellina_natural_medicine_questionnaire.pdf |
NOTICE OF PRIVACY PRACTICES
No signature required. This form is for your information only.
No signature required. This form is for your information only.
| notice_of_privacy_practices.pdf |
CAREGIVER CONSENT FORM
Please complete and return this form if someone other than a parent or legal guardian will be bringing your child in for a visit.
Please complete and return this form if someone other than a parent or legal guardian will be bringing your child in for a visit.
| stellina_caregiver_consent_form.pdf |
FOR PATIENTS TURNING 18
Congratulations! You are a legal adult! You are now in control of your health care, and all the details that come along with it. This means your parents can no longer make appointments for you, access your medical records or discuss your health with your doctor. Not ready to take that leap? Please complete and return this form to let us know if you would like your parents to continue to be involved.
Congratulations! You are a legal adult! You are now in control of your health care, and all the details that come along with it. This means your parents can no longer make appointments for you, access your medical records or discuss your health with your doctor. Not ready to take that leap? Please complete and return this form to let us know if you would like your parents to continue to be involved.
| snm_18__hipaa_parental_releas.pdf |