Patient Portal

Call Us: (203) 672-2800

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Our Location

52 Washington Avenue,
Suite 4
North Haven, CT 06473

Patient Forms

To help make your visit as smooth and efficient as possible, we ask that you download, print, and fill out the appropriate forms below based on the reason for your appointment. Please bring the completed forms with you to your visit. If you’re unable to print the forms ahead of time, no problem—just plan to arrive at least 20 minutes early so you’ll have time to complete the paperwork in the office.

PLEASE NOTE: All new patient paperwork is required for new patient visits, whether you choose to complete it beforehand or fill it out at the office prior to your appointment.

Download patient forms by clicking the links below.

New Patient Forms

CareMedica Registration Form

CareMedica Registration Form

CareMedica Authorization to Release Information Form

CareMedica Authorization to Release Information Form

CareMedica Patient Medical History Intake Form

CareMedica Patient Medical History Intake Form

CareMedica Notice of Privacy Practices (HIPAA Consent) Form

CareMedica Notice of Privacy Practices (HIPAA Consent) Form

CareMedica Policies Agreement Form

CareMedica Policies Agreement Form

Sexual Orientation Gender Identity (SOGI) Form

Sexual Orientation Gender Identity (SOGI) Form

Other forms

CareMedica Patient Treatment Contract

CareMedica Patient Treatment Contract

CareMedica AI Consent Form

CareMedica AI Consent Form

CPE (Complete Physical Examination)

GAD-7 Form

PHQ-9 Form

Tobacco Control Form

Tobacco Control Form

Audit-C Form

Social Determinants of Health (SDOH) Form

Social Determinants of Health (SDOH) Form

SPANISH Translated CareMedica Forms

Audit-C Form [SPANISH]

Audit-C Form [SPANISH]

GAD-7 Form [SPANISH]

GAD-7 Form [SPANISH]

PHQ-9 Form [SPANISH]

PHQ-9 Form [SPANISH]

Tobacco Control Form [SPANISH]

Tobacco Control Form [SPANISH]

Social Determinants of Health (SDOH) Form [SPANISH]

Social Determinants of Health (SDOH) Form [SPANISH]

CareMedica Policies [SPANISH]

CareMedica Policies [SPANISH]

Sexual Orientation Gender Identity (SOGI) Form [SPANISH]

Sexual Orientation Gender Identity (SOGI) Form [SPANISH]

CareMedica Patient Treatment Contract [SPANISH]

CareMedica Patient Treatment Contract [SPANISH]

CareMedica Patient Medical History Intake Form [SPANISH]

CareMedica Patient Medical History Intake Form [SPANISH]

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