Patient Forms

To download forms, click the links below. Please print and fill out these forms. Once complete, please email them to us at Christy.Sullivan@shcr.com or mail them to our Clearwater Office before your first appointment.

Patient History

• New Patient Questionnaire
• Patient Information
• Annual Questionnaire

Policy Acknowledgement

• Acknowledgment of No-Show Fee
• Acknowledgement of Class II or Class III Prescription Laws
• Medical Records Release
• Notice of Privacy Practices
• Acknowledgement of Receipt of Notice of Privacy Practices

Opioid Acknowledgement

• House Bill 452, Non-opioid Alternatives
• Opioid Consideration Questionnaire
• Opioid Risk Tool
• Opioid Therapy Consent
• Long Term Controlled Substance Consent
• FDA Warning Acknowledgment

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