Patient Information

Patient Forms

For new patients, these forms are here for completing prior to your scheduled appointment. If you are unable to
complete these forms before your appointment, we ask that you arrive 15 minutes early and please be sure to bring
a valid ID (driver’s license) and your insurance card. If this is your first visit with us, please bring all your medications with you to your appointment. For existing patients, these forms need to be filled out on a yearly basis.

All Patients

Welcome Form

Patient Registration Form

Prescription History Consent Form

For Children

Parental Consent Form

HIPAA Signature Form for Children

Health and Medical History Form

For Adults

HIPAA Signature Form for Adults

Health and Medical History Form

 

Inclement Weather

Please refer to channel 9 WSOCTV. If you contact our office, our recording will notify you if our office is to be closed
and/or what our hours of operation will be.
If our office is closed, please do not leave a message for the receptionist. If you have an emergency call 911 or go to
the emergency room.

No Show/Missed Appointments

In order to be good stewards of our schedule we encourage patients to keep their scheduled appointments. If
you no show or cancel your appointment without 24 hours notice you will be charges a no-show fee. Missed
appointments in our schedule deprive other patients access to timely medical care.

Patient Portal

Established Patients may utilize our patient portal and request an appointment. Simply go to the portal, complete
the appointment criteria and submit and book your appointment. Please be advised that Unifour Family Practice
only utilizes the patient portal to book same day appointments for acute patients only.
Existing patients my use the Healow App, which is an extension of our patient portal for your Smart phones and
tablets. Healow allows you to send and receive messages to your provider, track your medications, and send refill
requests, access personal health records, labs, vitals, progress notes, check your next appointments and receive
important alerts and reminders from our providers.

Insurance

We participate in most insurance plans, including Medicare, and several Medicare advantage plans. If you are not
insured by a plan we are contracted with, payment in full is expected at each visit. If you do not have an up-to-date
insurance card, payment in full for each visit will be required until we can verify your insurance coverage. Knowing
your insurance benefits is your responsibility. Please contact your insurance company with any questions you may
have regarding your coverage.

Vaccination Policy

We, the providers of Unifour Family Practice strongly believe in the proven safety and efficacy of childhood
vaccines. We fully support the much studied schedule of childhood immunizations recommended by the CDC and
the American Academy of Pediatrics.
We will not accept new patients who wish to immunize on a delayed schedule or completely refuse vaccines
altogether.

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