.tb-container .tb-container-inner{width:100%;margin:0 auto} [data-toolset-blocks-container="fb893b02b90648ec78ea36c3ef106acf"] { padding: 0 2em 4em 0; } .tb-grid,.tb-grid>.block-editor-inner-blocks>.block-editor-block-list__layout{display:grid;grid-row-gap:25px;grid-column-gap:25px}.tb-grid-item{background:#d38a03;padding:30px}.tb-grid-column{flex-wrap:wrap}.tb-grid-column>*{width:100%}.tb-grid-column.tb-grid-align-top{width:100%;display:flex;align-content:flex-start}.tb-grid-column.tb-grid-align-center{width:100%;display:flex;align-content:center}.tb-grid-column.tb-grid-align-bottom{width:100%;display:flex;align-content:flex-end} [data-toolset-blocks-grid="a3384fbdc6fa715d76fe850357a41ebd"] { grid-template-columns: minmax(0, 0.335fr) minmax(0, 0.665fr);grid-auto-flow: row } [data-toolset-blocks-grid="a3384fbdc6fa715d76fe850357a41ebd"] > .tb-grid-column:nth-of-type(2n + 1) { grid-column: 1 } [data-toolset-blocks-grid="a3384fbdc6fa715d76fe850357a41ebd"] > .tb-grid-column:nth-of-type(2n + 2) { grid-column: 2 } [data-toolset-blocks-grid-column="1880a39bad3b2c6fd27efe1237d1807f"] { padding-right: 7em;display: flex; } .tb-grid,.tb-grid>.block-editor-inner-blocks>.block-editor-block-list__layout{display:grid;grid-row-gap:25px;grid-column-gap:25px}.tb-grid-item{background:#d38a03;padding:30px}.tb-grid-column{flex-wrap:wrap}.tb-grid-column>*{width:100%}.tb-grid-column.tb-grid-align-top{width:100%;display:flex;align-content:flex-start}.tb-grid-column.tb-grid-align-center{width:100%;display:flex;align-content:center}.tb-grid-column.tb-grid-align-bottom{width:100%;display:flex;align-content:flex-end} [data-toolset-blocks-grid="3d9c399fe625e1b972f817a0680229f6"] { grid-template-columns: minmax(0, 0.5fr) minmax(0, 0.5fr);grid-auto-flow: row } [data-toolset-blocks-grid="3d9c399fe625e1b972f817a0680229f6"] > .tb-grid-column:nth-of-type(2n + 1) { grid-column: 1 } [data-toolset-blocks-grid="3d9c399fe625e1b972f817a0680229f6"] > .tb-grid-column:nth-of-type(2n + 2) { grid-column: 2 } [data-toolset-blocks-grid-column="3034fbe886c11054e95b46b09d3e4112"] { display: flex; } [data-toolset-blocks-grid-column="b6300e4a8e0fa3097ba0ac1902aae186"] { display: flex; } [data-toolset-blocks-grid-column="f586ff7bfe1d7317c63162ec7b7039ed"] { display: flex; } [data-toolset-blocks-grid-column="9c67e65643067cecaf355742166d673e"] { display: flex; } @media only screen and (max-width: 781px) { .tb-container .tb-container-inner{width:100%;margin:0 auto}.tb-grid,.tb-grid>.block-editor-inner-blocks>.block-editor-block-list__layout{display:grid;grid-row-gap:25px;grid-column-gap:25px}.tb-grid-item{background:#d38a03;padding:30px}.tb-grid-column{flex-wrap:wrap}.tb-grid-column>*{width:100%}.tb-grid-column.tb-grid-align-top{width:100%;display:flex;align-content:flex-start}.tb-grid-column.tb-grid-align-center{width:100%;display:flex;align-content:center}.tb-grid-column.tb-grid-align-bottom{width:100%;display:flex;align-content:flex-end} [data-toolset-blocks-grid="a3384fbdc6fa715d76fe850357a41ebd"] { grid-template-columns: minmax(0, 0.5fr) minmax(0, 0.5fr);grid-auto-flow: row } [data-toolset-blocks-grid="a3384fbdc6fa715d76fe850357a41ebd"] > .tb-grid-column:nth-of-type(2n + 1) { grid-column: 1 } [data-toolset-blocks-grid="a3384fbdc6fa715d76fe850357a41ebd"] > .tb-grid-column:nth-of-type(2n + 2) { grid-column: 2 } [data-toolset-blocks-grid-column="1880a39bad3b2c6fd27efe1237d1807f"] { padding-right: 4em;display: flex; } .tb-grid,.tb-grid>.block-editor-inner-blocks>.block-editor-block-list__layout{display:grid;grid-row-gap:25px;grid-column-gap:25px}.tb-grid-item{background:#d38a03;padding:30px}.tb-grid-column{flex-wrap:wrap}.tb-grid-column>*{width:100%}.tb-grid-column.tb-grid-align-top{width:100%;display:flex;align-content:flex-start}.tb-grid-column.tb-grid-align-center{width:100%;display:flex;align-content:center}.tb-grid-column.tb-grid-align-bottom{width:100%;display:flex;align-content:flex-end} [data-toolset-blocks-grid="3d9c399fe625e1b972f817a0680229f6"] { grid-template-columns: minmax(0, 0.5fr) minmax(0, 0.5fr);grid-auto-flow: row } [data-toolset-blocks-grid="3d9c399fe625e1b972f817a0680229f6"] > .tb-grid-column:nth-of-type(2n + 1) { grid-column: 1 } [data-toolset-blocks-grid="3d9c399fe625e1b972f817a0680229f6"] > .tb-grid-column:nth-of-type(2n + 2) { grid-column: 2 } [data-toolset-blocks-grid-column="3034fbe886c11054e95b46b09d3e4112"] { display: flex; } [data-toolset-blocks-grid-column="b6300e4a8e0fa3097ba0ac1902aae186"] { display: flex; } [data-toolset-blocks-grid-column="f586ff7bfe1d7317c63162ec7b7039ed"] { display: flex; } [data-toolset-blocks-grid-column="9c67e65643067cecaf355742166d673e"] { display: flex; }  } @media only screen and (max-width: 599px) { .tb-container .tb-container-inner{width:100%;margin:0 auto} [data-toolset-blocks-container="fb893b02b90648ec78ea36c3ef106acf"] { padding-right: 1em;padding-left: 1em; } .tb-grid,.tb-grid>.block-editor-inner-blocks>.block-editor-block-list__layout{display:grid;grid-row-gap:25px;grid-column-gap:25px}.tb-grid-item{background:#d38a03;padding:30px}.tb-grid-column{flex-wrap:wrap}.tb-grid-column>*{width:100%}.tb-grid-column.tb-grid-align-top{width:100%;display:flex;align-content:flex-start}.tb-grid-column.tb-grid-align-center{width:100%;display:flex;align-content:center}.tb-grid-column.tb-grid-align-bottom{width:100%;display:flex;align-content:flex-end} [data-toolset-blocks-grid="a3384fbdc6fa715d76fe850357a41ebd"] { grid-template-columns: minmax(0, 1fr);grid-auto-flow: row } [data-toolset-blocks-grid="a3384fbdc6fa715d76fe850357a41ebd"]  > .tb-grid-column:nth-of-type(1n+1) { grid-column: 1 } [data-toolset-blocks-grid-column="1880a39bad3b2c6fd27efe1237d1807f"] { padding-right: 0;display: flex; } .tb-grid,.tb-grid>.block-editor-inner-blocks>.block-editor-block-list__layout{display:grid;grid-row-gap:25px;grid-column-gap:25px}.tb-grid-item{background:#d38a03;padding:30px}.tb-grid-column{flex-wrap:wrap}.tb-grid-column>*{width:100%}.tb-grid-column.tb-grid-align-top{width:100%;display:flex;align-content:flex-start}.tb-grid-column.tb-grid-align-center{width:100%;display:flex;align-content:center}.tb-grid-column.tb-grid-align-bottom{width:100%;display:flex;align-content:flex-end} [data-toolset-blocks-grid="3d9c399fe625e1b972f817a0680229f6"] { grid-template-columns: minmax(0, 1fr);grid-auto-flow: row } [data-toolset-blocks-grid="3d9c399fe625e1b972f817a0680229f6"]  > .tb-grid-column:nth-of-type(1n+1) { grid-column: 1 } [data-toolset-blocks-grid-column="3034fbe886c11054e95b46b09d3e4112"] { display: flex; } [data-toolset-blocks-grid-column="b6300e4a8e0fa3097ba0ac1902aae186"] { display: flex; } [data-toolset-blocks-grid-column="f586ff7bfe1d7317c63162ec7b7039ed"] { display: flex; } [data-toolset-blocks-grid-column="9c67e65643067cecaf355742166d673e"] { display: flex; }  } 
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
Authorization To Speak To Others
Change Primary Care Providers Request Form
Driving Instructions to Arlington Main Campus
NC HealthConnex Opt Out (English)
NC Health Connex Opt Out (Spanish)
Request to Share Medical Records
Service Discontinuation – Bariatric Surgery
Patient Information Sheets
Specialty
Policies
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.