Documents & Forms

Save time and fill out forms before you arrive.

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Registration Forms

Our Patient Registration Forms packet is now available electronically for your convenience.

The registration packet includes:

  • Registration Form

  • Privacy Notice Acknowledgement

  • Patient Consent Form

  • Personal Medical History Form

Advance Directive

What is an advance directive and why is it important?

An advance directive informs physicians and other medical providers about a patient's treatment preferences in the event of a critical illness.

The advance directive is activated when a patient is deemed by a physician to be terminally ill or to have an irreversible illness/condition.

An advance directive:

  • Can be modified by the patient at any time

  • Cannot be overridden by anyone except the patient in sound mind

 

Advance directives can help to decrease suffering, increase the quality of life and improve comfort at the end of life. Specific directives could include the use of CPR or other resuscitation methods; life-sustaining equipment (dialysis/ventilator); artificial nutrition/hydration; and palliative care.

We at Samuel Dixon Family Health Center, Inc., urge you to have an advance directive. Inform your family of your desires and keep your card (downloadable below) with you in the event of an emergency.

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