The NeuroMedical Center’s Patient Forms

All forms and documents available for download are in PDF file format. Please complete the necessary paperwork prior to your visit.

The NeuroMedical Center Clinic

Internal Office Use Only

Clinic Patient Registration Form

All new Clinic patients must complete this form prior to their first appointment or if it has been more than three years since their last appointment. This form can also be used to update change of address.

New Clinic Patient Medication History Form

Authorization to obtain new Clinic patient’s Medication History

New Clinic Patient Intake Form

All new Clinic patients must fill out an assessment that addresses health history, current medications and systems to help determine appropriate care, treatment and services. Also necessary for patients who have not had a Clinic appointment for 3 or more years.

Notice of Privacy Practices

A clear explanation of individuals’ rights with respect to their personal health information.

Medical Record Release Form

Necessary for individuals seeking to obtain copies of Clinic medical records. Can be faxed or mailed.

Certification of Mobility Impairment Form

Required by the Office of Motor Vehicles for patients seeking to obtain a handicapped hang-tag and/or license plate. A physician must fill this form out for the patient to take to the Office of Motor Vehicles.

Physician Referral Form

Allows doctors and their staff to begin the process of referring a patient to The NeuroMedical Center Clinic.

The Spine Hospital of Louisiana

The Spine Hospital of Louisiana Medical Release Form

Necessary for patients seeking to obtain copies of their Spine Hospital of Louisiana medical records.

The Spine Hospital of Louisiana Sleep Study Referral Form

allows doctors and their staff to begin the process of referring a patient to The Spine Hospital of Louisiana Sleep Center.

Notice of Privacy Practices

A clear explanation of individuals’ rights with respect to their personal health information.

The NeuroMedical Center’s Patient Forms

The NeuroMedical Center Clinic

The Spine Hospital of Louisiana

The Rehabilitation Hospital

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