Forms

Each new patient must complete the following forms:

  1. SJMG Patient Registration Document
  2. Disclosure of Protected Health
  3. Financial Agreement including Consent

If the patient is scheduled to see a family practice provider they must also complete:

  1. Family Practice Patient History

If the patient is scheduled to see an internal medicine provider they must also complete:

  1. IM and Specialist Patient History

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LUTHERAN HEALTH NETWORK
BLUFFTON REGIONAL MEDICAL CENTER | DUKES MEMORIAL HOSPITAL | DUPONT HOSPITAL* | KOSCIUSKO COMMUNITY HOSPITAL*
LUTHERAN HEALTH PHYSICIANS | LUTHERAN HOSPITAL* | THE ORTHOPEDIC HOSPITAL* | REDIMED | REHABILITATION HOSPITAL*
ST. JOSEPH HOSPITAL*

*A physician owned hospital.

If you are experiencing a medical emergency, call 911.
Patients are seen in order of severity, therefore, your spot may not be guaranteed. In case of a life-threatening emergency, call 911.
Patient results may vary. Consult your physician about the benefits and risks of any surgical procedure or treatment.