Forms

These forms are for established patients. If you are completing application paperwork, click one of these links:

  1. Functional Medicine Program 1 Application Forms
  2. Functional Medicine Program 2 Application Forms

1. Updated Patient Disclosures

Established patient form

Please complete this form to update your required notices, consents, agreements and acknowledgements with Sparks Family Medicine, Ltd.

2. Patient Health Update

Established patient form

Please complete this form to update your medication/supplements, procedures/vaccines and health expectations.

3. Patient Information Update Packet

Established patient form

Please complete this form to update your contact, emergency contact, insurance and pharmacy information.

4. Controlled Substance Form #1 (Non pain medication)

Established patient form

Please complete this form prior to your visit to refill controlled substances other than pain medications.

5. Controlled Substance Form #2 (Pain medication)

Established patient form

Please complete this form prior to your visit to refill controlled substances for pain.

6. Patient Acknowledgement of Privacy Practices (Click Here)

Notice of Privacy Practices (Click Here)

New patient forms

The Patient Acknowledgement of Privacy Practices documents the patient’s receipt of the Notice of Privacy Practices as required by HIPAA. Only the Patient Acknowledgement form needs to be included in new patient paperwork.

7. Medical Records Release #1 (Records to SFM) 

New patient form (Optional)

Completion of this form is necessary to request a patient’s medical records from another health care provider. A fax number for the health care provider’s office is required. Patients can limit the type of health care information requested or select “All Records.” Medical Records Release #2 should be used to request that Sparks Family Medicine transfer your records to another health care provider.

8. Medical Records Release #2 (Records from SFM)

This for will allow you to request that your records be transferred to another health care provider. Patients can limit the type of health care information requested or select “All Records.”

9. State Specific Advance Directives, AARP (Click Here)

This website provides a drop down menu for state specific Advance Directives forms. Advance Directives provide guidance to your loved ones and health care professionals regarding your health choices.

10. Nevada Living Will Lock Box (Click Here)

This form provided by the Nevada Secretary of State’s office provides information and resources regarding Advance Directives, including the Living Will Lockbox program that provides a virtual lockbox for Advance Directives, living wills, and “do not resuscitate” orders.