Phone: (225) 769-4044

Helpful Forms for Download

The Baton Rouge Clinic provides the following forms to save our patients time in the waiting area, provide a venue for feedback and allow new patients to contact us.

 

* MEDICAL RECORDS: Release of Protected Health Information:

Release FROM The Baton Rouge Clinic, AMC
Release TO The Baton Rouge Clinic, AMC

* MRI FORMS: Questions, surveys and authorization forms.

MRI Procedure History Form (pdf)
MRI Screening Questionnaire (Hazard Checklist, pdf)
MRI Patient Instructions (pdf)

* MISCELLANEOUS FORMS:

Mammogram Questionnaire (pdf)
Bone Density Study Questionnaire (pdf)
Sleep Questionnaire (pdf)

* HEMATOLOGY / ONCOLOGY NEW-PATIENT FORMS:

Medical History Form (pdf)
Medication List Form (pdf)