Patient Forms

Our forms library is intended for your convenience.   It will save you time during your visit.  You’ll have more time to reference your prior records so that your history will be complete and thorough.

You will need to complete and submit these forms upon becoming a patient of AETC Primary Care. We suggest that you complete and sign each of them prior to your first visit to our clinic.  Doing so will afford you ample time to review them and save you time during your visit.

Move your cursor over the document you wish to download and click. Complete the forms using Acrobat, save for your records and print. Bring the completed forms with you for your appointment.

All documents are in Adobe PDF.  
If you do not have Abode Acrobat Reader, you may download it here.
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Patient Info Update Form
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Medical History Form 

If you a are new patient to our Primary Care Practice, please complete our on-line “Medical History” form prior to your first visit.  Simply type your information on the form presented to you on the screen.  When you have completed the form, click the “Print Button” on the bottom of the last page (Page 5).  Be sure to bring it with you on your first visit.  Please note:  The reset button will clear the form.

Patient Info Update Form

Please complete this on-line form prior to your next visit.  Simply type your information on the form presented to you on the screen.  When you have completed the form, print it.  Be sure to bring it with you on your next visit.

Notice of Privacy Practices 

Please read, print and sign this document prior to your first visit as a patient.

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abitration
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Financial Policy/Legal Assignment 

Please read and sign this document prior to your first visit as a patient. Doing so will afford you ample time to review them and save you time during your visit

Arbitration
Agreement 

(Print and sign this form.)
Any dispute as to medical malpractice, that is as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently or incompetently rendered, will be determined by submission to arbitration as provided by state and federal law, and not by a lawsuit or resort to court process except as state and federal law provides for judicial review of arbitration proceedings.

Policy On
Advanced Directives

(Print and sign this form.)
The State of Arizona regulations require that your medical chart contains the following information. You will be asked if you have a Living Will, have assigned a Medical Power of Attorney, or designated a “surrogate” to act on your behalf. We suggest that you read and sign each component of this document prior to your first visit as a patient. Doing so will afford you ample time to review them and save you time during your visit.

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Insurance Plan Policy

Please read, print and sign this form.  Please make sure that you fully investigate the coverage of your insurance plan with your insurance company before you undergo any medical services including labs, x-rays, blood tests and other diagnostic procedures.  You must agree by completing this form to be solely responsible for knowing the terms and conditions of your insurance plan.