Patient Forms

For your convenience, we have supplied our general patient forms below.  If you wish, click on the link below, print, complete the form, and bring it with you to your appointment.  Printing them, filling them out and bringing them with you will allow us to attend to your medical needs more quickly than completing them on your arrival.

Registration Forms

Patient Rights, Responsibilities & Financial Policies

Patient Consent Forms

HIPAA Release Forms

If you are interested in obtaining your medical records, please complete the form below. HIPAA forms can mailed or brought in-person to our center only. Patients can not make online requests for records.

Please use the form above for releasing information to and from Callen-Lorde. For further assistance, please call our Medical Records department at 212-271-7137.

Application for Income-Based Discount 

If your income information has changed since we last saw you, please fill out the following form.

Application for Income-Based Discount

Research Consent

Consent to Contact

Please fill out this consent form if you are interested in participating in research studies.

Telehealth Consent

Consent Form

Please fill out this consent form to receive telehealth services.