Initial Appointment Forms

Please print out each of the following forms, fill them in, and bring them with you to your first appointment.  If you are scheduled for a telehealth appointment, please make sure we receive them prior to your appointment.  You can drop them off, mail them, or fax them to our office.  We do not accept email.

Patient Information Form (in PDF)
Please fill out this Patient Information Form as best as you can and bring it to the initial appointment.

Notice of Privacy Practices (in PDF)

Acknowledgement of Receipt Form (in PDF)
Please sign and date this form. It acknowledges that you received a copy of the Privacy Policy.

Release of Information Form (in PDF)
This form, when completed and signed by you, authorizes me to release protected information from your clinical record to the person(s) you designate.  Please include your emergency contact person.

Service Agreement

Medicare Document

Kissing Bridge, Waterville, Vermont Painting by Bill Schmidt

Kissing Bridge, Waterville, Vermont
Painting by Bill Schmidt


PRIVACY POLICY
(c) 2012-15 Nancy C. Wheeler, M.D. |133 Defense Highway, Suite 114 | Annapolis, MD 21401
410-266-9181