Welcome to Moukdad Medical. Once scheduling opens, new patients will be asked to complete the registration forms below prior to their first visit. Forms may be completed securely through our Patient Portal or downloaded and printed to bring to your appointment.
A single, easy-to-download packet that covers your health history, insurance, and required office policies — everything you’ll need for your first appointment.
Please do not email completed forms. Bring printed copies to your first visit or complete them securely through the portal.
Want to know what’s inside the full packet? Each form is listed below so you can review or download them individually if needed.
Collects demographics, insurance, medical and social history, and preventive care details.
Confirms you have reviewed our Notice of Privacy Practices outlining how your information may be used and shared.
Explains our financial procedures, consent for treatment, and insurance authorization.
Describes your rights and responsibilities as a patient and our commitment to equitable care.
Provides consent for secure video or phone visits when appropriate.
Allows setup of your secure online portal and specifies how you’d like to receive communications.
Authorizes secure storage of a payment method for copays and balances.
Allows you to list specific individuals — such as family members, caregivers, or others you trust — who may access or discuss your medical information.
Authorizes Moukdad Medical to send or obtain your records from another provider.
Provides consent for injections such as B12, testosterone, or flu vaccines.
Outlines safe and responsible use of controlled medications (e.g., ADHD, anxiety).