Click on the following links to download our online forms:Endocrinology Questionnaire Internal Medicine Questionnaire Pulmonary Questionnaire Rheumatology Questionnaire Neurology Questionnaire
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 firstname.lastname@example.org
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 Request for Medical Records
Asks for demographics, insurance information etc. for business officeFor patients to fill before the visit.
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
This notice provides information regarding how medical information about you may be used and disclosed.Notice of Privacy Practice (HIPAA)
GI Procedures InstructionsColonoscopy-Movi-Prep Colonoscopy-Prepopik Prep Colonoscopy-Suprep Prep
GI Procedures InstructionsColonoscopy-Miralax-Prep
GI Procedures InstructionsColonoscopy-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
GI Procedures InstructionsColonoscopy-Miralax-Prep Colonoscopy-EGD Prep
GI Procedures InstructionsEGD Prep Capsule-Miralax-Prep Miralax-Prep
GI Procedures InstructionsColonoscopy-Miralax-Prep Colonoscopy-Suprep 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.