Below you will find our patient forms. All forms are interactive PDFs. Click links to download to your device or open in the browser; fill in your information and save.
Email completed forms to firstname.lastname@example.org, or print and bring to your next visit.
Please note: If you choose to email forms, the email consent form must accompany the first email. By filling in your name electronically on the forms, you are agreeing that your electronic signature is the legal equivalent of your manual signature.
Authorization for Email Communication
Email Consent (Please initial all lines and sign at the bottom of second page)
All new patients must complete the following five forms.
Established Patients Follow Up Appointments
Email this form with updated information to email@example.com 4 days prior to your next visit.
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.
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.