Call Us: (203) 672-2800
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      Our Location

      52 Washington Avenue,
      Suite 4
      North Haven, CT 06473

      Patient Forms

      IMPORTANT

      PLEASE       download, print, and complete the appropriate forms based on your appointment type. Bring the completed forms with you to your visit. If you are unable to print them in advance, PLEASE ARRIVE AT LEAST 20 MINUTES EARLY to complete the paperwork in-office prior to your appointment. 

      PLEASE NOTE: All new patients are required to complete new patient paperwork, either in advance or upon arrival.
       

      Download patient forms by clicking the links below.

      New Patient Forms

      CareMedica Registration Form

      CareMedica Registration Form
      Authorization to Release Information

      Authorization to Release Information
      Patient Medical History Form

      Patient Medical History Form
      Notice of Privacy Practices (HIPAA)

      Notice of Privacy Practices (HIPAA)
      CareMedica Visit Policies Agreement

      CareMedica Visit Policies Agreement
      Review of Systems [Questionnaire]

      Review of Systems [Questionnaire]
      Social Determinants of Health (PRPARE) Form

      Social Determinants of Health (PRPARE) Form

      Other forms

      CareMedica Patient Treatment Contract

      CareMedica Patient Treatment Contract
      CareMedica AI Consent Form

      CareMedica AI Consent Form

      Physical Examination

      General Anxiety Disorder (GAD-7) Questionnaire

      General Anxiety Disorder (GAD-7) Questionnaire
      Depression Screening (PHQ-9) Questionnaire

      Depression Screening (PHQ-9) Questionnaire
      Tobacco Questionnaire

      Tobacco Questionnaire
      Alcohol Screening (Audit-C) Questionnaire

      Alcohol Screening (Audit-C) Questionnaire
      Social Determinants of Health (PRPARE) Questionnaire

      Social Determinants of Health (PRPARE) Questionnaire
      Review of Systems Questionnaire

      Review of Systems Questionnaire

      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]
      CareMedica Patient Treatment Contract [SPANISH]

      CareMedica Patient Treatment Contract [SPANISH]
      CareMedica Patient Medical History Intake Form [SPANISH]

      CareMedica Patient Medical History Intake Form [SPANISH]
      Review of Systems Questionnaire [SPANISH]

      Review of Systems Questionnaire [SPANISH]

      Get More Info

      Get More Info

      Online Patient Portal

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      Visit Our Other Medica Companies:

      Laser Medica
      Weight Medica
      CareMedica Elite
      American Medica

      Are you a Health Care Professional looking to join CareMEDICA?

      Full-time and part-time opportunities available for motivated primary care healthcare professionals in a thriving medical practice, with offices located in Greater New Haven, CT, and Palm Beach County, FL. Unique career opportunities with unlimited professional and financial gratification. For more information and consideration please send resume/CV and salary history to careers@caremedica.com

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