Patient Forms

Click on the following links to download our online forms:

  Endocrinology Questionnaire  Internal Medicine Questionnaire  Pulmonary Questionnaire  Rheumatology Questionnaire  Neurology Questionnaire  Gastroentorology Questionnaire

Patient Request for Medical Records (Non-HIPAA)

Use this form to request copies of your medical records either for yourself or to be provided to another party. Please fax the completed form to 501.604.8799, or scan and email the completed form to recordsrequest@lrdc.com

Notice: This form is not HIPAA compliant and cannot be used by third party request companies, attorneys, insurance companies or any other outside facilities. This form is only to be submitted by patients and/or patient’s representatives.

  
Patient Information Form

Asks for demographics, insurance information etc. for business office

  For patients to fill before the visit.
Authorization For Disclosure of Protected Health Information

Use this form to authorize LRDC to discuss your protected health information with another party, such as a spouse or child.

  Authorization For Disclosure of Protected Health Information
Notice of Privacy Practice (HIPAA)

This notice provides information regarding how medical information about you may be used and disclosed.

  Notice of Privacy Practice (HIPAA)
Dr. Angtuaco

GI Procedures Instructions

  Colonoscopy-Movi-Prep  Colonoscopy-Prepopik Prep  Colonoscopy-Suprep Prep
Dr. Coppola

GI Procedures Instructions

  Colonoscopy-Miralax-Prep
Dr. Hughes

GI Procedures Instructions

  Colonoscopy-Movi-Prep 7am - 10am appointment  Colonoscopy-Movi-Prep 11am or later appointment  Colonoscopy-Prepopik Prep 7am - 10am appointment  Colonoscopy-Prepopik Prep 11am or later appointment  EGD-Suprep Prep
Dr. Jones

GI Procedures Instructions

  Colonoscopy-Miralax-Prep  Colonoscopy-EGD Prep
Dr. McElreath

GI Procedures Instructions

  EGD Prep  Capsule-Miralax-Prep  Miralax-Prep
Dr. Dhaval Patel
  Colonoscopy-Miralax Prep
Dr. Svoboda

GI Procedures Instructions

  Colonoscopy-Miralax-Prep  Colonoscopy-Suprep Prep  Colonoscopy-EGD Prep
Dr. Williams

GI Procedures Instructions

  Colonoscopy-Miralax-Prep  Colonoscopy-EGD Prep

*Disclaimer: If this is a true medical emergency please contact the Emergency Medical Services (911), or go to the nearest emergency room.