We are happy that you chose us for your care. In this section, we house a variety of forms that you may need to fill out, whether you are a new patient or coming in for a follow-up visit. Each form is accessible in PDF format for you to download and fill out before arriving.
Our information is available in PDF format, which requires Adobe Acrobat Reader. If you do not have Acrobat Reader, please click here to download it.
New patients must complete all new patient information forms prior to or at their first appointment. You will be given these forms when you visit the office or you may download them at the link below.
Download New Patient Packet
Our welcome letter provides important information about your visit, including our address, a map to our location, and what to bring with you to your appointment.
Download Welcome Information
Patient Information Form
New patients must fill out this form so we can start a file and keep them current. You will be given this form when you visit the office or you may download the form from the web site.
Download Patient Information Form
Health Questionnaire Form
Patients must complete this form so we can keep an accurate profile of your medical history and your current condition. You will be given this form when you visit the office or you may download the form from the web site.
Download Health Questionnaire Form
Notice of Privacy Practices/HIPAA Acknowledgement Form
Patients must review our Notice of Privacy Practices and fill out a HIPAA Permission To Disclose Information form. You will be given this form when you visit the office or you may download the form from the web site.
Download Notice of Privacy Practices/HIPAA Acknowledgement Form
Patient Financial Policy
Patients must read and sign the Patient Financial Policy to indicate that they have read and accept the terms provided.
Download Patient Financial Policy
Medical Record – Release of Information Form
We provide up to two years of medical records at no cost. Please contact our office if you need medical records beyond two years. Medical Records: 317-885-2860, ext. 4978 or email us at MR@iimconline.com
A Release of Information Authorization form must first be completed by the patient or legal guardian prior to requesting medical records.
Download Release of Information Authorization Form