Initial Appointment Forms

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

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