Family Healthcare Patient Registration Form

Platte County Health Department has offered me a copy of their "Notices of Privacy Practices"
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I hereby grant permission to the Platte County Health Department to obtain laboratory speciments or perform minor procedures ordered by the provider or by the nursing staff operating under standing orders. I also understand it is my responsibility to contact Platte County Health Department for all test results if I have not received results within two weeks. All positive STD results will be reported to the Missouri Department of Health and if HIV positive or TB positive, I will be offered management services. NO prescriptions (refills or new) will be called in after business hours.
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I hereby authorize The Platte County Health Department to use telemedicine in the course of my diagonosis and treatment.
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Email*
example@example.com
All services are confidential; however, in the event that we do need to contact you regarding a lab results, may we identify ourselves as the Platte County Health Department?*

YesNo
Please indicate where we CAN call/leave a message with you:
Home: Home Phone Number* Cell: Cell Phone Number*
Work: Work Phone Number* Other: Other Phone Number*
Enter 0000 for those that are blank
Please list to whom your medical records may be released to:
Name: Full Name Date: Date
Name: Full Name Date: Date

Patient Registration