Patient Forms

Your medical history is imperative to a successful visit!

Please print and complete all forms prior to your appointment. If you prefer to fill out the forms in person, we ask that you arrive at least 30 minutes before your scheduled appointment time.

Our patient services representatives are here to help! Give us a call at 480.428.3232, or email us at psr@scnm.edu.  

Intake Forms Please download the intake form that applies to you (or the patient being seen):

• Patient Intake Form (Adult, 16 years and older)
• Patient Intake Form (Child, 0-15 years)

New Patient Forms: Download and complete all of the following consents and legal documents:

• Patient Rights and Responsibilities
• Confidential Patient Demographic Form
• Notice of Privacy Practices
• Acknowledgement of Receipt of Notice of Privacy Practices
• Patient Payment and Appointment Cancellation Policy
• Consent for Treatment

• Consent for Acupuncture Treatment Form
• Electronic Communication Consent

For a Copy of Your Medical Records

Download and complete this form:

• Medical Records Release Form

You can fax, scan/email, or drop it off in person to patient services at SCNM clinics. We will send your medical records within 30 days.

Fax: 480.970.0003

Email: psr@scnm.edu

Address: 2164 E Broadway Rd. Tempe, AZ 85282

In order to download any of the forms, you will need Adobe Acrobat Reader.  If you need a free copy of Adobe Reader, please click here.