Breezewood Healthcare, PA
   
     
If you have been asked by our office to complete forms prior to your visit, please select the appropriate form(s) below.  Download, print and complete the form(s) you were asked to complete and bring with you to your visit.  If you are unsure as to what form(s) to complete, please contact our office at (910) 485-0700.
  • New Patient Registration Forms

    All new patients are required to show 30 minutes prior to their first appointment. This allows us to process your information and get your history to your provider. However, by downloading and filling in these forms prior to your visit you can greatly reduce your wait time and visit time at our office.

  • BH Medical History Forms

    If you are an established patient of Breezewood Family Healthcare and haven't been seen in 2 years or more please fill this form out. This will help catch your provider up on any changes in your medical history and can reduce you time in the office.

  • BH Medication Chart

    Filling this chart out prior to all your visits will help your practitioner in providing you the best possible healthcare.

    We recommend that you include all vitamins and any herbal supplements that you may be taking.

  • Patient Consent Form

    This form simply states that you understand your rights under the Health Insurance Portability & Accountability Act of 1996 (HIPPA) and that you understand how Breezewood Family healthcare, P.A. will use this information.

  • BH Consent To Treatment

    This form is utilized if you have given your provider consent to evaluate and treat your menopause, andropause, thyroid disorders, adrenal fatigue/stress and other hormone imbalances by the administration of bioidentical hormone replacement therapy and/or nutritional supplements, including vitamins, minerals and anti-oxidants and/or drugs designed to alter hormone levels.

  • Type 2 Diabetes Action Plan

     

    Get the most from your doctor appointments by coming prepared with this planning sheet. Make notes for yourself below so you’ll have the information you need on hand, along with any questions you want to share with your provider.

     

  • HCG

    This form is utilized to give your provider consent to evaluate and manage your weight loss, utilizing our HCG program.

  • Preparing for Your FLT Appointment

    Our consultation time with you is important! You can get maximum benefit from the time reserved for your consultation by being prepared. So please review the How To Prepare! section of this document and make the most of your first visit.

  • BH Blood Pressure Tracking Sheet

    A simple tracking sheet to help document your pressures and help your provider help you in maintaining healthy blood pressures.

  • Medical Release Form

    This authorization is for Breezewood Healthcare, P.A. to release information being requested of you, by you, in order to comply with the terms of the Confidentiality of Medical Information Act.

    This may take as much as 30 days to complete and there may be charges that apply.