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Locate The Appropriate Patient Form
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.
PATIENT FORMS
Advance Directive North Carolina
Includes forms for Healthcare Power of Attorney and Living Will
Alternative Communication and Privacy Form
Authorization to Disclose Health Information (Revocation)
Patient request to stop permission to provide records.
Endoscopy Center Pre-Packets
Carolina Endoscopy Center
Carolina Digestive Endoscopy Center
New Patient Registration Forms
New Patient Appointment Referral
Open Access Referral Form (English)
Open Access Referral Form (Spanish)
Patient Interview Form
Patient Responsibility
Patient Responsibility (Spanish)
Patient Responsibility (Vietnamese)
Patient Rights
Patient Rights (Spanish)
Patient Rights (Vietnamese)
Privacy Practices Notice
Request for Release of Medical Information
For release of other physician’s records to Carolina Digestive.