Forms

Below are some forms that you can print and hopefully save you a little time at your first or next visit:

New Patients

Patient Information Form. We keep this form on hand for every patient. Please take the time to fill it out, sign it, and bring it in on your first visit (or at any time your address, telephone, or employment changes).
Patient History Form.  Save the doctor time by filling out your medications, current and past problems, as well as medical family history.
Patient Arbitration. DO NOT sign this form. Read through this form to better understand our CVMG Arbitration Agreement, but please sign a copy at your visit so you can keep a signed copy.
Notice of Privacy Practices.  You should read this document before signing the second line of the Patient Information Form.

Pediatrics

Scout Physical. Please bring this form in when receiving any scouts physicals. This page may take a few minutes to download.
5 Year Old Well Child Check.  Parents can fill out this portion of the questionnaire beforehand. Feel free to select your answers and print the form.
4 Year Old Well Child Check.  Parents can fill out this portion of the questionnaire beforehand. Feel free to select your answers and print the form.
3 Year Old Well Child Check.  Parents can fill out this portion of the questionnaire beforehand. Feel free to select your answers and print the form.
Sleep Questionnaire. Fill out this form before coming to see the doctor concerning sleeping issues for your child.
Temperament Questionnaire.  Fill out this form previous to your visit concerning your child's temperament.

Physicals

Scout Physical. Please bring this form in when receiving any scouts physicals. This page may take a few minutes to download.
DOT Physical. Feel free to print this form and fill out certain portions before you come in for your DOT or CDL physical.

Students

Student Medication Authorization.  Bring this form (provided by the Nebo School District) to your child's visit if you would like them to be able to self-administer medications at school.
Student Inhaler Authorization.  Have your provider sign this form to allow your child to self administer asthma medications while at school.
Student Diabetes Authorization. Have your provider sign this form to allow your child to self administer diabetes medications while at school.