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Online Forms - for NEW PATIENT registration 
For All New Patients 

Forms 1, 2, 3, 4, 5a are required to establish as a patient in our practice.

  • If you wish to become a patient, we request you print out/download the forms and fill them out prior to your appointment.
  • Note: All patients, we have an Annual Administrative Fee of $60 (if age 25 and older) or $30 (if age 24 or younger) - see form below for questions concerning this - it is required yearly starting at your first appointment to establish in the office.
  • Note: we only accept cash or credit/debit cards (Visa, Master Card, American Express and Discover) - we do not accept checks
1) Medical History Form

* Required at time of 1st visit
This supplies the doctor with pertinent medical history.
2) Office Registration and Portal Web Access Form

* Required at time of 1st visit
This supplies the office with pertinent demographics/contact info.
3) Patient Agreement & Insurance - Financial Notification

* Required at time of 1st visit
This provides the business with a necessary financial agreement regarding medical services.
4) Admintrative Annual Fee - Consent and Explanation

* Required at time of 1st visit
This provides the business with a necessary financial agreement regarding non-medical/non-insurance services.
5a) Acknowledgement of Notice of Privacy Practices

* Required at time of 1st visit (We need form 5a signed and returned, not 5b)
This form is require by state or federal agencies to acknowledge we provided you with our Notice of Privacy Practices (form 5b)
5b) Notice of Privacy Practices

For your reading and review - we don't need this form returned, but you should read prior to signing accompanying form 5a.
6) Medical Records Release / Request Form

* Optional - if needed
Note: we request only a limited amount of pertinent prior health records; typically no more than 1 - 2 years.  Please don't bring in copies of multiple years worth of prior health records. We prefer you to write the requested medical history on our health history form (form #1).
7) Consent for Minors

* Optional - needed for any patient under the age of 18.

Other forms 
Diabetic glucose log

For our diabetic patients:

  1. Download, print and fill in your sugar levels.
  2. Bring in to your appointment.
  3. We prefer reviewing your glucose levels in this format - as opposed to looking at the results in your meter which is difficult to analyze trends etc

North Scottsdale Internal Medicine
8575 E. Princess Dr., Suite 109
Scottsdale, Arizona 85255
(480) 502 - 9355 phone
(480) 502 - 6017 fax

Copyright 2008 © North Scottsdale Internal Medicine. All Rights Reserved.

Important disclaimer: The information on this site, including on www.nsmedicine.com is provided as a supportive service to North Scottsdale Internal Medicine and Mark J Lewis, MD, PLC and is not meant to replace the advice of the physician who cares for you. All medical advice and information should be considered to be incomplete without a physical exam, which is not possible without a visit to your doctor.