Forms

We are committed to getting you in and out of your appointment as efficiently as possible. If you are a new patient, please fill out all five English/Spanish forms below and email them to amedical@avenue360.org. 

Patient Registration 

—Formulario de Inscripcion

Patient Rights & Responsibilities 

—Derechos y Responsabilidades del Paciente

Patient Prescription Medication Consent

—Consentimiento de Recetas Electronicas

Patient Medical Consent

—Authorizacion para Divulgar Information de Salud

Income and Insurance

—Informacion sobre Ingresos y Seguros

Telehealth at Avenue 360

To telehealth patients: Please fill out the forms above and this additional one:

Telehealth by phone or online

COVID-19 Vaccine

Consent and Screening Form for COVID-19 Vaccine

Forma de Consentimiento y Revisión para la Vacuna del COVID-19