Getting To Know You So We Can Provide the Best Care

Maintaining accurate and comprehensive medical records is very important to your care. Your medical history can affect your treatment plan, so we need to have all of the facts. 

We make the process of filling out patient forms as convenient as possible, allowing you to have paperwork filled out before you get to our office. Download the forms below by clicking the blue buttons marked “Download this Form.” Then, you can print out the forms, fill them out, and bring them to your appointment.

New Patient Forms

Maintaining accurate and comprehensive medical records is very important to your care. The forms below can be downloaded by clicking the blue buttons marked “Download this Form”, printed and brought to your appointment.

New Patient Information

These forms are for all new patients to fill out and bring to the clinic upon their first visit. These forms give you the option of (1) filling out the forms on your personal computer, printing them, and bringing them with you, or (2) printing out the blank forms, filling them out with a pen, and bringing them with you.

New Pediatric Patient Information

This form is for all new pediatric patients. It is to be filled out by a parent or guardian and brought to the clinic upon the child’s first visit. This form gives you the option of (1) filling out the form on your personal computer, printing it, and bringing it with you, or (2) printing out a blank form, filling it out with a pen, and bringing it with you.

Notice and Acknowledgement of Privacy Practices

Protecting the privacy of your medical information is required by law, and we respect and carefully abide by that law. You should carefully read these forms – and then acknowledge your acceptance of their conditions by signing should you choose to do so. These forms must be completed and returned to the clinic at the time of a patient’s first visit. You should list the names of person(s) that are permitted access to your (or the patient’s) protected health information. No information can or will be shared with anyone who is not listed on this form.

Current Patient Forms

Maintaining accurate and comprehensive medical records is very important to your care. The forms below can be downloaded by clicking the blue buttons marked “Download this Form”, printed and brought to your appointment.

Information Change Form

The Information Change form should be filled out when there is any type of change in the patient’s information, whether it is an address, policy number, etc. The entire form must be completed regardless of the information that has changed. Please present the form upon your arrival to see a doctor. Keeping your information accurate and current allows us to provide you with better health care and ensure your claims are paid promptly.

Medical Record Request

This form is for patients who choose, for any reason, to have their medical records transferred to any other location or health care provider.

Have Any Questions About These Forms? Give Us a Call!

Barg Family Clinic will be closed on Monday, April 8, 2024 due to the Solar Eclipse as Little Rock is in the direct path of this event. We have carefully considered the difficulties this event will place on our patients and staff as we are facing multiple school closures and an expected 1.5 million out of state visitors that will cause extreme travel concerns this day. We will have a provider on-call throughout the day. Should you have an emergent medical need that cannot wait until we re-open, you can reach our on-call provider at 501-580-0840. Thank you allowing us to serve you for your healthcare needs!