General Information
       


Patient Forms


For your convenience, Facey has made our registration forms available here on our website.
To save time, fill out the appropriate form and bring them with you to your first appointment, along with your insurance card and a photo ID.   Adobe Reader® will be needed to open the forms, and can be obtained here.

The documents marked by ** need to be read, completed and/or signed before your child's first visit, and before certain services can be provided.

 

Peds Registration (Ages 0-17)
  Patient Information Sheet  **
  Pediatric Medical History  **
  Temp. Auth for Consent to Treat a Minor
  Information Regarding Third-party Consent 
 
MyChart

The Proxy form needs to be turned in directly to the Doctor's office in person. Adults can register in person at the time of their next Doctor's appointment.

  MyChart - Proxy Access Form
  MyChart - Proxy Access Form - Spanish

 

 
Privacy & Information Release
  Welcome from Health Information Management
  Notice of Privacy Practices *
  Acknowledgement of Notice of Privacy Practices **
  Amendment Request Form *
  Restriction Request Form *
  Authorization to Release Medical Information *
     - English     - Spanish
 

Please be aware that these forms can not be submitted online, at this time.