For your convenience, we have provided the essential forms online to help expedite your initial visit to the office. The forms can be downloaded and printed at your convenience. If possible, please complete them prior to your initial visit to the office. If you have any questions, please contact the office at (209) 723-6624.

Patient Information Sheet

  • This form is used to gather important demographic and insurance information that will be required at the initial office visit. The information will be placed in your file for future reference and verified at each subsequent visit.

Patient Health Summary

Family History Cancer Questionnaire

  • Adobe PDF: ENGLISH
  • These forms will provide us with your important background health information, which will assist the physician in providing the appropriate care for you.

Privacy Policy

  • This form explains the office privacy policy, which is HIPPA-compliant. All of your health and treatment information is protected and secured in our office.

Records Release Form

  • Adobe PDF: ENGLISH *
  • This form is used to give Merced Ob/Gyn Care, Inc. authority to release your medical record and its information to other requesting entities. This form also allows the office to request copies of your health/medical records from other entities—this is especially important for patients who transfer their care from other providers. You have the option to decline the release of your health information from this office—this will be noted in your medical chart.

Patient Portal Agreement

  • Adobe PDF: ENGLISH
  • This form allows our staff to create a patient portal account for you. The patient portal can be used to view your chart information, request appointments, pay your bill online, and more.

Financial Policy - Summary and Consent

BRCA Health Record Release Form

*These forms are not needed at your initial visit