STELLINA NATURAL MEDICINE
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  • Our services
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  • COVID-19/Coronavirus
  • Contact
  • For Patients
    • Patient Portal and Confidential Email
    • New Patients Aged 13+
    • Forms
    • Resources
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                         FORMS

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.
Patient portal
Confidential Email

AUTHORIZATION TO RELEASE HEALTH CARE INFORMATION
This form is required if you would like records released from or to your doctor.
snm_recordsrelease2022.pdf
File Size: 176 kb
File Type: pdf
Download File

​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.
stellina_caregiver_consent_form.pdf
File Size: 104 kb
File Type: pdf
Download File

​FOR PATIENTS TURNING 18
Congratulations!  You are now 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_age18_hipaa_parental_release.pdf
File Size: 140 kb
File Type: pdf
Download File

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  • Home
  • Our services
  • Our Physicians
  • Insurance
  • COVID-19/Coronavirus
  • Contact
  • For Patients
    • Patient Portal and Confidential Email
    • New Patients Aged 13+
    • Forms
    • Resources