Patient Forms

Please choose a link to access the appropriate forms. Our forms may change as we add automation to the website. You will only be able to print these forms. Please bring completed forms to your appointment. Our website cannot process these forms at this time.

All CDHA forms are saved as PDF and require Adobe PDF Reader to view. If you do not have Adobe PDF Reader on your browser, please click on the link below and install.

Install Adobe Reader to View Forms


Endoscopy Center Forms:

Patient Rights

Patient Rights in Spanish

Patient Rights in Vietnamese

Patient Responsibility

Patient Responsibility in Spanish

Patient Responsibility in Vietnamese

Advance Directive North Carolina
Includes forms for Healthcare Power of Attorney and Living Will

Privacy Practices Notice

Alternative Communication and Privacy Form

Endoscopy Center Pre-Packet
 

Procedure Prep Instructions


Medical Record Release Forms:

Request for Release of Medical Information

For release of other physician’s records to Carolina Digestive

Authorization to Disclose Health Information

Patient permission to provide Carolina Digestive’s records to others

Authorization to Disclose Health Information – Revocation

Patient request to stop permission to provide records


New Patient Registration Forms:

Please print and complete New Patient Registration form below.

  • Please bring completed forms with you at the time of your visit.
  • Do Not mail these forms prior to your visit.

New Patient Registration Forms


Financial Assistance Forms:

Financial Assistance Application


All CDHA forms are saved as PDF and require Adobe PDF Reader to view. If you do not have Adobe PDF Reader on your browser, please click on the link below and install.

Install Adobe Reader to View Forms