Patient Forms

Below you will find our patient forms. Please click links to download and fill out the forms you need.

New Patients

All new patients must complete the following four forms.

New Patient Registration Form
Arbitration Agreement Form
Office Policy
Patient Representative Release Authorization

Medical Information Release

For Dr. Klausner to obtain medical records from and or release records to another doctor, please fill out the following form which applies.

Medical Records Release Form to Dr. Klausner
Medical Records Release Form from Dr. Klausner

Lyme Disease Forms

Below you will find our Lyme Disease patient forms. Please click links to download and fill out the forms you need. All patients currently being treated by Dr. Klausner for Lyme need to fill out the Lyme preappointment patient update form and return to Dr. Klausner at least 3 days before each in person or telephone appointment.

Horowitz/MSIDS Lyme Questionnaire
Preappointment Patient Update
Informed Consent
C. Difficile Acknowledgement

Email Authorization for Medical Records

Email consent

 

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