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FaceyConnect - Patient Portal

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PATIENT FORMS

- para espanol, presione aquí
 

For your convenience, Facey has made our patient registration forms available online. After filling out the appropriate forms, please bring them with you to your first appointment, along with your insurance card and a photo ID.   Please be aware that, at this time, these forms can not be submitted to Facey electronically.    Adobe Reader® will be needed to open the forms, and can be obtained here.

*All patients must read and/or sign the Privacy documents noted by the asterisks * below.

Adults (Ages 18 & up)
Pediatrics (Ages 0-17)
Patient Information Sheet
Pediatric Medical History
Temp. Auth for Consent to Treat a Minor
Information Regarding 3rd-party
Consent
 
Obstetrics & Gynocology (OB/GYN)
First Visit to the OB Office
Genetic Screening Information Sheet
 
Advance Directives
  • English 788 KB
  • Spanish 900 KB
  • Spanish-English 3.7 MB
  • Chinese-English 4 MB
  • Korean-English 3.7 MB
  • Tagalog-English 3.7 MB
  • Privacy & Information Release
    Welcome from Health Information Mgmt
    Notice of Privacy Practices *
    Acknowledgement of Notice of Privacy Practices *
    Amendment Request Form *
    Request for Confidential Verbal Communication

    Status Change for Confidential Communication
    Restriction Request Form *
    Authorization to Release Medical Info *

    Internet Privacy Policy
     
    Additional Resources
    Prescription Refills FAQ

    New Patient Welcome Packet

    Facey Phonebook 2.3 MB