For your convenience we have made all of our patient information forms available online. You may download and print the forms so that they may be completed prior to your appointment.
By completing forms in advance, it will not only save time during the check in process but will also allow you to give us the most complete and accurate information.
Please take the time to complete each page so that we will have all of the information needed to best serve you & your family.
The Surgical Clinic of Central Arkansas Patient Information Forms
The New Patient Information Form below is to be completed by each new Surgical Clinic patient. Complete each section, if that sections does not apply, (i.e., you have not had any previous surgery) please indicate that by “none” or “not applicable” in the space provided. Please do not leave any blank sections.
Breast Surgery Associates Patient Information Forms
The Breast Patient Forms below are for Dr. Hagans’ patients only. If you are scheduled to see another physician please use the Patient Information Form forms in the section above. Complete each section, if that sections does not apply please indicate that by “none” or “not applicable” in the space provided. Please do not leave any blank sections.
Release of Information
This form gives your physician’s office permission to send your records to us. You may print out the form & present it to your other physicians, releasing them to submit records on your behalf.
Notice of Privacy Practices
This Notice of Privacy Practices is being provided to you as a requirement of the Health Insurance Portability and Accountability Act (HIPAA). This Notice describes how we may use and disclose your protected health information to carry out treatment, payment or health care operation and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information in some cases.
Bariatric or weight loss surgery patients
Please see our bariatric website for the appropriate forms. www.ArkansasBariatricSurgery.com