Patient Forms & Policies

Patient Forms & Policies

We want to help you speed up the paperwork process when you arrive for your visit. For your convenience, we have provided our office forms here for you to print, complete, and bring along to your next scheduled visit.

Patient Questionnaire Form
Authorization to disclose health information
Designated Individuals Authorization Form
Medication Log
 

We ask you to complete these forms once per year and bring to your annual visit. However, should you have medical conditions that need to be updated in your medical record, we ask that you complete a new form and bring to your next visit.

For all appointments we ask that you bring the following:

  • Insurance Card
  • Co-pay
  • A copy of your current medication list
  • Changes in address or phone  number

Notice of Privacy

Call us today to find out more about our Monthly Specials on Beauty Products and Medical Aesthetics.

Medical Phone & Hours

Medical Phone #

Mon – Thurs

Fri

Sat - Sun

336-667-8341

8:30am to 4:45pm

8:30am to 11:45pm

Closed

Med Spa Phone & Hours

Med Spa Phone #

Mon – Fri

Sat - Sun

336-667-5358

8:00am to 5:00pm

Closed

Copyright © 2017 Foothills Center for Women All Rights Reserved | 112 Boone Trail North Wilkesboro, NC 28659 | 336.667.8241

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