NEW PATIENTS: Please complete the new patient questionnaire(s) and email, mail or fax back to us before your visit at:
or fax to 720-676-1703.
The other forms are provided for your review only. You will be asked to sign the other forms during your first visit and yearly thereafter.
RETURN PATIENTS: No need to print any forms, but you will be asked to sign the forms at your first visit to Center for Multisystem Disease and yearly thereafter.
NEW PATIENT QUESTIONNAIRE
If you have both dysautonomia and APS, please complete the dysautonomia questionnaire first and then complete the questions of pages 3 and 4 of the APS questionnaire that you have not already answered on the POTS/dysautonomia questionnaire.
OVERALL FUNCTIONAL ABILITY SCORE
Please refer to this form when you are completing the New Patient Questionnaire.
We will also provide this form to you to complete before office visits.
MEDICAL RECORDS RELEASE
Please complete if you need to have your outside records sent to us.
HIPAA PRIVACY NOTICE
All patients must complete this form yearly.
Please complete yearly if you or your provider may want to communicate with our office by email.