Patient Information
  • Patient Information

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  • Format: (000) 000-0000.
  • Please upload a clear photo of the front and back of your insurance card and your photo ID. See examples below.

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  • Medical Records Request

  • Release These Records
  • Reason for Release
  • Signature Date
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  • Are you signing as the patient?
  • Clinic Policies Acknowledgement

  • Summary of Key Clinic Policies:

    • Payment is due before your visit. You may inquire about payment plans. Insurance deductibles must be met before coverage begins.
    • No-shows and late cancellations will incur fees and may result in dismissal from the practice.
    • Medication refills and questions require scheduled visits. This helps maintain patient safety and documentation integrity.
    • Controlled substances are not guaranteed and may require drug testing and monthly follow-up if approved.
    • The clinic operates strictly as a primary care clinic and does not provide urgent or emergency care services.

    Grievance and Complaints Process:
    We value your feedback. If you have concerns or complaints about the care you receive, you may contact our clinic administrator in person or by calling 559-369-7787. All grievances will be addressed within 10 business days.

     

    Consent to Communication:
    By signing below, I consent to receiving communications regarding my care via phone, voicemail, SMS, or email. I understand that The Modern Medicine Group does not use online messaging portals like MyChart and requires appointments for direct clinical interactions.

    Consent to Care:
    I understand and agree to abide by all clinic policies as outlined. I consent to be treated by The Modern Medicine Group and understand that clinic policies may be updated from time to time.

     

    Read Full Policy PDF

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  • HIPAA & Communication Preferences

  • Who can receive info?
  • Messaging preferences (Please call)
  • If unable to reach me
  • Date
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  • Health Questionnaires

  • PHQ-9 (Patient Health Questionnaire-9)

  • Little interest or pleasure in doing things
  • Feeling down, depressed, or hopeless
  • Trouble falling or staying asleep, or sleeping too much
  • Feeling tired or having little energy
  • Poor appetite or overeating
  • Feeling bad about yourself — or that you are a failure or have let yourself or your family down
  • Trouble concentrating on things, such as reading the newspaper or watching television
  • Moving or speaking so slowly that other people could have noticed? Or the opposite — being so fidgety or restless that you have been moving around a lot more than usual
  • Thoughts that you would be better off dead or of hurting yourself in some way
  • GAD-7 (Generalized Anxiety Disorder-7)

  • Feeling nervous, anxious, or on edge
  • Not being able to stop or control worrying
  • Worrying too much about different things
  • Trouble relaxing
  • Being so restless that it is hard to sit still
  • Becoming easily annoyed or irritable
  • Feeling afraid, as if something awful might happen
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  • If you need help completing forms, call:  559-369-7787

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