Simon Clinic Harrison Ar

Phone: 870-204-5645 | Fax: 855-701-1410

Patient Forms

Print and fill out before your appointment

Forms are provided for you to print and fill out at your convenience. Remember to bring your completed forms with you on the day of your appointment. If you are unsure what forms may be needed, please call and speak to a member of our staff.

Required forms must be filled out if you are a new patient or if your information has changed. Required forms are:

  • Patient Data Form
  • Health History
  • Consent and Acknowledgement

Please also read our Office Policies and Notice of Privacy Practices. Other forms may be requested when your appointment is made.

Forms (9)

* Required before initial visit      
Medical Treatment Consent Form       Download
HIPPA Authorization Form*       Download
Patient Agreement*       Download
Patient Data Form*       Download
Privacy Practice Acknowledgement*       Download
Telehealth Visit*       Download
MEDICAL Records Release       Download
Notice Privacy Practices       Download
Office Policies Patient Information       Download