900 NE 139th Street, Ste 202, Vancouver, WA 98685
CURRENT PATIENTS: (360) 566-9355
CONCIERGE INQUIRIES: (360) 553-1730
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Forms

Forms

We are honored that you have selected the providers of Creekside Medical to assist you with your healthcare needs. Below is a list of the most common forms you will need.

All forms must be filled out in blue or black ink only. 



Records Release Information

  • Medical Records Release


Registration Forms

  • New Patient Registration Forms
  • Annual Update Forms
  • Disclosure Authorizations
  • Follow Up Policy
  • HIPAA-2019
  • HIPAA Acknowledgement
  • Patient Rights
  • Making an Appointment


Financial

  • Credit Card Authorization
  • Assignment of Benefits
    

    School Forms

    • Authorization for Medication in Vancouver SD
    • Vanderbilt ADHD Parent Assessment
    • Vanderbilt ADHD Teacher Assessment
    • Vanderbilt ADHD Parent Follow-up
    • Vanderbilt ADHD Teacher Follow-up
    • WIAA Physical Form
    

    Pediatric Dosing

    • Pediatric Dosing Chart – Acetaminophen
    • Pediatric Dosing Chart – Benadryl
    • Pediatric Dosing Chart – Ibuprofen
    

    Misc. Medical Forms

      • Advanced Directive Packet
      • Authorization to Provide Medical Care to Unaccompanied Minor
      • Patient Consent for Use and Disclosure of Protected Health Information

     

    Contact

    Creekside Medical
    Concierge Care

    Internal Medicine & Pediatrics

    900 NE 139th Street, Ste 202
    Vancouver, WA 98685

    Office Phone: (360) 566-9355

    All Are Welcome

    All patients deserve to have high-quality healthcare, in a safe environment.

    Anyone who enters Creekside Medical will be treated with respect, dignity, and kindness. We take pride in having an inclusive practice and we welcome you here.

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