Lake Rheumatology: Dr. K. Stark & Dr. N. Blum

Available Forms

#1 New Patient Information #2 Medication List & Drug Allergy List #3 Consent for Non-Face to face "Virtual" Visits #4 Comprehensive Patient History Questionnaire #5 Labs And Prescription Policy #6 Patient Call List #7 No Show Fee Financial Agreement #8 Rapid Questionnaire-Only if instructed #9 Osteoporosis Questionnaire

#7 No Show Fee Financial Agreement

Kenneth Stark, M.D., P.A.

Date *

Name *

Date Of Birth *

If I miss an appointment and do not give the office a minimum of 24 hours notice, I agree to pay a fee of $60 for New Patients, $25 for follow up visits, $25 for Bone Densitys and $50 for Infusions.

BY CHECKING THE BOX BELOW, I ACKNOWLEDGE I HAVE READ AND UNDERSTAND THIS AGREEMENT, AND THEREFORE AGREE TO THE TERMS OF THE FINANCIAL AGREEMENT. I ALSO UNDERSTAND CONFIRMATION CALLS ARE A COURTESY, BUT IT IS ESSENTIALLY MY RESPONSIBILITY TO KEEP TRACK OF MY APPOINTMENT.

I Agree *

Yes

* Required field