Dr. Robina Poonawala, M.D. and Dr. Munira Khambati, M.D.
Family Practice Center South
DOWNLOAD REGISTRATION FORMS
For your convenience, you may print out the following registration forms, complete at your own pace and bring with you along with your driver’s license and medical insurance cards to your first appointment.
Patient Information Form: Please complete your personal information, insurance and billing responsibility and your preference of where to contact you about your diagnostic test results.
Patient Information Form
Medical Records Release: If you have seen any physicians or other healthcare practitioners, this release gives us permission to obtain your medical records. Medical Records Release Form
Financial Policy: Please read our office Financial Policy and sign where it asks for your signature.
Financial Policy Form
History & Physical: This detailed background health questionnaire gives us important information about your health history and current healthcare needs. History & Physical Form
Privacy Practices: Review of your patient rights and for your records. Privacy Practices Form
Remember to bring all completed forms to your first appointment! If you have any questions, feel free to bring them to your visit with the Physician.