Complete Your Forms
Forms Before Appointment
Easy Access to Your Forms
- Log in to your patient portal.
- Find the 'Forms' section on your dashboard.
- Select and complete the required forms for your visit."
Important Forms and Documents You'll Need
New Patient Registration Form
Complete this form with your personal information and medical history.
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Pembroke Consent for Treatment
Consent form granting permission for medical treatment at Pembroke Wellness.
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HIPAA Acknowledgment Form
Review and acknowledge our privacy practices in compliance with HIPAA.
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Pembroke Insurance Appointment Policy
Insurance policy details and appointment guidelines for patients.
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Spence Anxiety Scale
A comprehensive scale to assess anxiety levels in patients.
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Privacy Practices Part 2 (Patient Keeps)
Important privacy guidelines and patient rights for safeguarding personal information.
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Pembroke HIPAA Privacy Agreement
Agreement outlining Pembroke’s compliance with HIPAA privacy standards.
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Pembroke HIPAA Notice of Privacy Practices
Official notice explaining how Pembroke collects, uses, and protects patient information.
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Pembroke Financial Policy
Financial policy form outlining payment expectations and insurance information
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Pembroke Consent for Treatment ( 2 )
Another version of the consent form for patient treatment at Pembroke Wellness.
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Pembroke Authorization Request Form
Form requesting authorization for the release of patient medical information.
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Patient Rights and Responsibilities (Patient Keeps)
A patient-friendly version of the rights and responsibilities document for personal reference.
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Patient Rights and Responsibility
A detailed overview of patient rights and responsibilities at Pembroke Wellness.
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Notice of Privacy Practice
A formal notice detailing how Pembroke Wellness adheres to privacy laws and practices.
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Notice of Privacy Practice (Patient Keeps)
A version of the privacy notice for patients to keep for their records.
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Medication Consent Form
Authorization form for prescribed medications during treatment.
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Insurance Policy
Details about insurance coverage and policies at Pembroke Wellness.
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HIPAA Receipt and Acknowledgment
Confirmation that the patient has received and understands Pembroke’s HIPAA policies.
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Financial Policy
Outlines billing, payment, and financial responsibilities for patients.
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Depression Scale for Children
A screening tool to assess depressive symptoms in children.
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Copy of September/November 2024 Basic Training Participants
Consent for Treatment
Agreement allowing medical treatment and care at Pembroke Wellness.
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Consent for Telehealth
Consent form for receiving virtual healthcare services.
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Child/Adolescent History
A form collecting medical and personal history for young patients.
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Authorization for Use and Disclosure Pembroke Wellness
Authorization to release or share medical information as needed
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Adult Personal History
A form documenting personal and medical history for adult patients.
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24-Hour Coverage Notice
Information about Pembroke’s 24-hour care availability and policies.
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