Patient Forms

Patient Forms

From pri­ma­ry care for the whole fam­i­ly to expert spe­cial­ty care, The South Bend Clin­ic is equipped to diag­nose and treat your med­ical needs, large and small. Becom­ing a patient is eas­i­er than ever with a few sim­ple steps to com­plete before your first appointment.

Adobe Read­er is required to dis­play and print the forms below. You may down­load Adobe Read­er for free at www​.adobe​.com. At the time of your next vis­it, please bring the down­loaded and com­plet­ed forms with you

HIPAA

• Autho­riza­tion for Release of Health Infor­ma­tion Form
• SBC Ver­bal Release Consent
• SBC HIPAA Con­sent

Radi­ol­o­gy

• Radi­ol­o­gy Exam Prep Form

Busi­ness Office

• Finan­cial Pol­i­cy Form
• Work­man’s Com­pen­sa­tion Form

Pri­ma­ry Care

• Medicare Well­ness Vis­it Form

Spe­cial­ty Care 

Aller­gy & Immunology

• New Patient Age 5 and older
• New Patient Age 4 and younger

Der­ma­tol­ogy

• New Patient Form
• Return Vis­it Form

Gas­troen­terol­o­gy

• Low Fiber Diet 3 Day
• Low Fiber Diet 5 Day

Phys­i­cal Med­i­cine and Rehabilitation

• Wel­come Form
• New Patient Rights Form
• Health His­to­ry Form

Rheuma­tol­ogy

• New Patient Form