Forms

The following are forms that need to be filled prior to our first clinic visit:

Now that I am online, there are a few options for filling out forms. You do it the old fashioned way print it, fill it out, take a picture or scan the signed document and email (pratistha.strong@gmail.com) it to me or fax it to 432-614-2599:

• Kathmandu Clinic Patient Agreement and Clinic Policies Signature Page (Please click here if you would like to access the patient agreement and clinic policies document)

• Patient Profile

• Medical Release of Information (I have made this a fillable form. You may have to print this and sign it. Otherwise hospitals and doctor’s offices will not accept this form.)

• CMS Opt-Out This is for Medicare patients only. This is a fillable form.(You may have to print this and sign it.)

• Medical Cannabis Safety Sheet Signature Page This is for Medical Marijuana patients only. (Please click here if you would like to access the Medical Cannabis Safety Sheet)

• Medicaid OPR Agreement This is for Medicaid patients only.

You can use Google Forms and do the same submission online. At this point I do not have a Medical Release of Information form or the CMS Opt-Out form that is equal to the Google Forms.

• Kathmandu Clinic Patient Agreement and Clinic Policies Agreement (Please click here if you would like to access the patient agreement and clinic policies document)

• Patient Profile

• Medical Release of Information (I have made this a fillable form. You may have to print this and sign it. Otherwise hospitals and doctor’s offices will not accept this form.) This is the same as above.

• CMS Opt-Out This is for Medicare patients only.

• Medical Cannabis Safety Sheet Agreement This is for Medical Marijuana patients only. (Please click here if you would like to access the Medical Cannabis Safety Sheet)

• Medicaid OPR Agreement This is for Medicaid patients only.

For return phone visits, it is helpful if I know what symptoms you are having for your visit. Please fill the following form out:

• Review of Systems

The following are for reference only. You do not need to print this or sign it.

• Notice of Privacy Practice (For reference only. No need to print.)

• Kathmandu Clinic Patient Agreement and Clinic Policies (For reference only. No need to print.)

• Medical Cannabis Safety Sheet (For reference only. No need to print.)