CARY ADULT MEDICINE - Publicforms

Available Forms

Back Pain E-Visit Billing Question Blood Pressure Log Blood Sugar Readings Cold/Flu/Sinus/Cough//Throat/Respiratory Infection Comments or Suggestions Conjunctivitis/Pink Eye Depression Screening (PHQ9) Flu Shot Health Care Question HIPPA Hospitalization Insurance Change Form Lab Result Follow-up Question Living Will/Health Power of Attorney Medical History/Preventative Update Medicare Wellness Exam New Patient Medical History New Patient Registration Form On Demand Appointment Registration Password - Patient Request for Secure Password Patient Education Classes Prescription Refill Request Preventative Care Referral Question Specialist/ER/Hospital/Testing Update Specialist/Urgent Care or Hospital Visits Survey- Cary Adult Medicine Telemed Urinary Tract Infection Voluntary Alignment for Medicare ACO REACH Yeast Infection

Preventative Care

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Colonoscopy

Please check this box if you are over age 50 and under 85 and have not had a colonoscopy after the age of 50 or within the past 10 years. Please also check this box if at your last colonoscopy polyps were found and your repeat colonoscopy is due. Please note we do not recommend a colonoscopy after age 85 and only for some individuals between ages 75 and 85 We will be in contact with you to help set-up your exam

Mammogram

Please check this if you are a female between the ages of 50 and 75 and have not had a mammogram within the past 2 years. We will be in contact with you to help you set-up the exam.

Pneumococcal Pneumonia Shot

If you are over age 65 and have not had a pneumococcal pneumonia shot please check this box and we will contact you to set-up a time for the vaccination.

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