Forms & Policies

Provided below are various forms that require completion prior to your visit and/or surgery. Please download the appropriate form as directed by your physician and/or staff by clicking on the name of the form. Please bring the completed form(s) with you to your scheduled visit. This will help expedite the registration process. Thank you.

General Forms

Authorization Release Health Information Form (Form must be notarized)

Authorization To Speak To Others (Form must be notarized for verbal sharing of information only, no written records to be shared.)

Bone Density Questionnaire

Change Primary Care Providers Request Form

Patient Information Sheets

Specialty

Location

Dermatology

Endocrinology

Gastroenterology

Hematology/Oncology

Infectious Disease

Internal Medicine

Pulmonary

Rheumatology

Surgery

Quadrangle Endoscopy Center Financial Policy

Quadrangle Endoscopy Center Cost Estimate for Upcoming Services

Beulaville

Farmville

Greenville OB/GYN

Greenville Women's Clinic

Grifton

Kinston

Winterville

Policies

Hours, Appointments & Providers Brochure

Notice of Privacy Practices

Patient Financial Responsibility Policy

Request to Share Medical Records

In accordance with the North Carolina Controlled Substances Reporting Act (GS 90-113.70), the statewide controlled substances reporting system may be referenced when controlled medications are prescribed.