​Visit Planning Forms:

Please complete a pre-visit form for all visits.
For an annual wellness visit, choose the form for your gender and age below.
For a follow up visit or a visit for a new concern, please use this form:
Visit Planning Form
(If you prefer a printable form click: Printable Visit Planning Form)

Pre-visit forms for Adult Wellness Visits:
 - Women 65 and older
 - Men 65 and older
 - Woman under 65
 - Men under 65
(If you prefer a printable form click:  Woman or Man)

Wellness Pre Visit Forms for Children:

These forms are only available in a format to be printed. Please call if you would like a form mailed or set out for you before your visit.

New born
1 month
2 months
4 months
6 months
9 months

1 year
18 months
2 years
2 1/2 years
3 years to 12 years
Teenagers and young adult

Other forms:
Blood Pressure Goal and Tracking Form
Waiting list for Dr Hearst

Materials for annual pain management visits (Coming soon)

Notices:
Privacy Notice
Community Health Team Policy

New Patients:
Please complete all three of these documents:
Registration Form
Acknowledgement of Policies
Record Release