Patient Forms
Lincoln Surgical knows your time is valuable, so to save time at your first appointment we ask that you download, print, and return the forms below.
By completing this information prior to your visit, you will shorten your total time for your initial office visit. You will also improve the exchange of information that will help us serve you better.
You can mail or bring these forms to our office prior to your meeting with one of our surgeons. Or you may bring the completed forms to your office appointment, but please allow yourself some extra time for that visit.
Instructions
The following files are in PDF Format. To view a PDF file, download and install Adobe Acrobat reader from Adobe Systems. Right-click and “Save Target As” to save a form to your desktop. Open the PDF form. There are two form options below: forms that can be filled out electronically or by hand.
Once complete, print and bring your forms to our office or fax your form to us at 618.277.7422. Forms cannot be submitted online or electronically.
Electronically Fillable Forms
Directions: Click anywhere and start typing.
- Breast History Form – Fillable
- Health History Form – Fillable
- HIPAA Form – Fillable
- Patient Authorization Form – Fillable
- Patient Demographics Form – Fillable
- Risk Assessment for Hereditary Breast and Ovarian Cancer Syndrome Form - Fillable
- Vasectomy Patient Form – Fillable
Printable Forms
Directions: Print and fill out by hand.
- Breast History Form – Non-Fillable
- Health History Form – Non-Fillable
- HIPAA Form – Non-Fillable
- Patient Authorization Form – Non-Fillable
- Patient Demographics Form – Non-Fillable
- Risk Assessment for Hereditary Breast and Ovarian Cancer Syndrome Form - Non-Fillable
- Vasectomy Patient Form – Non-Fillable
If you have any questions about the forms above or if you would like to schedule an appointment, please contact us.
Privacy Practices
The practice provides its Notice of Privacy Practices to every patient with whom it has a direct treatment relationship. To read the full privacy policy, please download and read the PDF.