Forms

Forms to bring to your visit

Medicare Wellness Annual Visit
For Medicare and Medicare Advantage patients coming in for their “Welcome to Medicare” visit or their Annual Wellness Visit.

Patient Agenda
Bring this simple form to every office visit. Our providers encourage patients to use this form because it makes it easier for you to communicate all your concerns at the beginning of the visit.

New Patient History: Adult / Child
Some providers may ask you to complete this form prior to your first visit.

Privacy and consent forms

Medical Records Release
Complete this form to have your medical records transferred from another practice to FPG or from FPG to another practice.

Consent to Release Information to Family - HIPPA Adult
Your privacy is important to us, so please tell us whether you permit us to share your health information with your family members, such as a spouse.

Consent to treat your child - HIPPA Child
Until your children are 18, they must have a parent, legal guardian or other approved caregiver with them for their appointment. In order for us to know who has permission to give consent for care of your child, their name must be on this form. If you need to add or update this information please fill out this form.

Flu Vaccine Information and Release
Please complete this in advance of receiving your annual flu vaccine.

Advance Directives
Advance Directives are legal documents that describe your wishes for your healthcare when you are unable to speak for yourself. This booklet describes the different types of Advance Directives and includes Colorado’s version of these forms. For a much briefer description of the types of Advance Directives, click here.

Health screening forms

ADHD Assessments: Parent Initial / Parent Follow-Up / Teacher Initial / Teacher Follow-Up

Patient Health Questionnaire-9: PHQ-9

Colonoscopy prep instructions

Dr Pflieger: Colon Prep

Dr Lobitz: Colon Prep

CONTACT US

New Patient Inquiry / Non-Medical Questions

contact

* All indicated fields must be completed.
Please include non-medical questions and correspondence only.

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Mon – Fri: 7:30am - 5pm
Sat: 8am - 12pm

Our Locations

(970) 356-6928

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(970) 353-2801

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(970) 587-7738

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(970) 378-8088

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