Patient Forms

Authorization to Disclose Information

URPG Financial Assistance Application Packet

Bariatric Surgery

Gastric Bypass Surgery – After You Are Home
Gastric Bypass Surgery – Day Of Your Surgery
Gastric Sleeve Surgery – Day Of Your Surgery
Lap Band Surgery – After You Are Home
Lap Band Surgery – Day Of Your Surgery
Laparoscopic Sleeve Gastrectomy – After You Get Home

Endocrinology

Patient Questionnaire – Dr. Mai
Consent for Treatment of a Minor
Office and Financial Procedures

Family Medicine

Cancellation Information
New Patient Form
Payment Policy Guidelines
Consent for Treatment and Assignment of Benefits

Internal Medicine

Consent for Treatment of a Minor
Office and Financial Procedures

Neurosurgery

Carpal Tunnel Surgery – After You Are Home
Carpal Tunnel Surgery – Your Hospital Stay
Cervical Surgery – Afer You Get Home
Crainotomy – After You Get Home
Craniotomy- In Hospital
Lumbar Surgery – In the Hospital
Neurosurgery Back
Neurosurgery Neck
New Patient Form
Peroneal Release Surgery – After You Get Home
Peroneal Release Surgery – In the Hospital
Preparing For Surgery
Thorascopic Sympathectomy – After You Get Home
Thorascopic Sympathetomy – Your Surgery and Hospital Stay
Ulnar Surgery – After You Get Home
V-P Shunt Surgery – Your Hospital Stay
V-P Shunt Ventricular-peritoneal shunt – After You Get Home
Vertebroplasty and Kyphoplasty – After You Get Home

Obstetrics & Gynecology

After Your Essure Procedure
Family History Questionnaire – Hereditary Cancer Syndromes

Orthopedics

New Patient Form

Podiatry/Foot and Ankle Surgery

New Patient Form
Patient Questionnaire – Dr. Mai
Payment Policy Guidelines
URPG Consent for Treatment and Assignment of Benefits

Rheumatology

Consent for Treatment of a Minor
Office and Financial Procedures

Sports Medicine

New Patient Form