Patient Forms

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 drklausnersoffice@gmail.com, 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)

New Patients

All new patients must complete the following five forms.

New Patient Registration Form
Arbitration Agreement Form
Office Policy
Patient Representative Release Authorization
Informed consent no Medicare coverage

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.

MSIDS Horowitz/MSIDS Lyme Questionnaire
Lyme Preapppointment Patient Update
Informed Consent for Lyme
Lyme Consent for treatment
Lyme Progress Notes 
C. difficile Patient Acknowledgement

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