Outpatient Forms

Outpatient Forms

 

The forms on this page are for patients of Pine Rest’s outpatient clinics only. If you have any questions, please call 866.852.4001.

New Patient Forms

Our new patient forms can now be completed online.

  1. Go to MyChart sign up page.
  2. Get your MyChart Activation Code from the email you were sent. If you can’t find your email or it’s been more than 2 weeks since you received the email, please call us to get a new activation code.
  3. Once you’ve activated your MyChart account, complete the forms waiting for you..

If you do not have an appointment, please call 866.852.4001.

If you are a Telehealth client, you must complete the online forms through MyChart.


Please bring a completed New Client Form to your first visit if you do not complete the online form in MyChart.

Print out the appropriate form for you, your child or your patient. The form must be completed in black or blue ink.

Child: Age 11 or under

Adolescent: Age 12 – 17

Adult: Age 18 and over

Release of Information Forms

In order to share your Protected Health Information (PHI), you will need to complete and sign a Release of Information form. Please complete the form below.

PRINTABLE RELEASE OF INFORMATION FORM

If you are a Telehealth client, you must complete the online form.

All other Pine Rest patients may use this printable Release of Information form.


Please complete the form below in black or blue pen. A sample has also been supplied.

ONLINE RELEASE OF INFORMATION FORM

Please do not use this online form if you are a Pine Rest INPATIENT or PARTIAL HOSPITALIZATION patient. Use the printable form instead.

If you have questions, please call 866.852.4001.