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Forms

General Description
New Patient Pack This is a complete pack of forms for new patients
New Patient Information This form contains Charis Clinic basics
Patient Registration Form This form contains patient address, insurance, contact information, and other registration information
Medical Records Authorization This authorization form directs your other medical providers to release your medical records to the Charis Clinic
Health Information By Alternate Means This form authorizes Charis Clinic to leave health information for you bCarey email, voice message or text
Financial Policies This form contains our financial, payment and credit card policies.
Acknowledgement Privacy Practices This form acknowledges receipt of our privacy practices
Primary Care Description
Pediatric Medical History Our medical history form for patients under 14 years of age
Adult/Adolescent Medical History Our medical history form for patients 14 years old and older
PHQ-9 & GAD-7 Forms This contains the PHQ-9 & GAD-7 screening forms
Aesthetic Care Description
Botox Cosmetic Consent This form grants consent for Botox procedures
Botox Cosmetic Instructions Instructions for Botox patients
Cosmetic Client Questionnaire Questionnaire for suitability for cosmetic procedures
Cosmetic Juvederm & Botox Consent This form grants consent for Botox and Juvederm
Filler Consent This form grants consent for filler injections
IPL Pre and Post Treatment Instructions Patient instructions for before and after IPL treatment
IPL Hair Removal Treatment Instructions Patient instructions for before and after IPL hair removal
Laser Light Energy Consent General consent for IPL procedures
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