Patient Forms | Dr. Whitney Mostafiz

Patient Portal and Office Forms

In an effort to be paperless as well as optimize office hygiene in light of COVID-19, new and existing patients may use the Patient Portal to fill out Online Forms.

For your convenience, PDF forms are also included below to view or use alternatively.

The COVID Health Questionnaire is REQUIRED < 24hrs. prior to EACH scheduled appointment. Telehealth Consent is required to utilize electronic/remote services. A signed copy of the COVID Office Guidelines is required for both existing and new patients.

Thank you for your cooperation and understanding. #flattenthecurve

- Dr. Whitney

ADULT HEALTH HISTORY

UNDER 18 HEALTH HISTORY

HIPPA FORM

PHOTO RELEASE

COVID QUESTIONNAIRE

PATIENT OFFICE GUIDELINES

AAO INFORMED CONSENT

TELEHEALTH CONSENT

HIPPA: To review the Notice of Privacy Practices, please copy and paste this link into your web browser:
https://www.hhs.gov/hipaa/for-individuals/guidance-materials-for-consumers/index.html