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

#6 Patient Call List

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

Date *

Name *

Date of Birth *

By checking the box below, you agree to the following

I give permission for Dr. Kenneth Stark's Office to speak with the following people regarding all of my medical information. Including but not limited to; test results, office appointments, and billing information. Please include phone numbers for each person listed.I understand this will be in effect until I have notified Dr Stark's office in writing that I wish to remove this person from my call list.

Please include name and relationship to you

If you DO NOT wish us to speak with anyone, please check this box.

I do not give permission for Dr. Stark's office to speak with anyone other than myself regarding my healthcare.

* Required field