Form Name Description Who Should Use This Form
Submit Patient Information
An Online Form for new and existing patients to submit personal contact and insurance information. All New Patients, and Established Patients wishing to update their personal information.
New Patient Package Important forms to print out and sign for your first visit.  These forms include our cancellation policy, a privacy notice, a consent to treat form and our payment policy. New Patients before their first visit.
Medical History A 2 page form to be printed, completed and brought to the office.  This contains essential medical information needed to complete your health record. All New Patients, and Established Patients wishing to update their health records.
Health Care Proxy Print and bring in this form to designate another person as  a proxy.  This form enables a patientís proxy to make medical decisions for the patient, if the patient is unable (because of incapacity) to make medical decisions on their own behalf.
Any patients requiring this special service.
Complete Physical History    
(for Dr. Shallish)
Print out and complete this form before coming in for a complete physical examination with Dr. Shallish. Any Dr. Shallish patient going in for physical exam.
Medical
Records
Release Form- Outgoing
Print out and complete this form when requesting your medical records to be sent to another doctor or specialist. Established patients going to another doctor.
Medical
Records
Release Form- Incoming
Please print out this form when requesting your medical records to come to us from another medical provider. Any patient who is requesting their medical records to be sent to Family Medicine Associates from another provider.
Annual Wellness Report Pediatric (Ages 1-5)
Print out and complete this form prior to your child's well visit if your insurance is the Cornell Program for Healthy Living (CPHL) from Aetna.  
Annual Wellness Report Pediatric (Ages 6-17) Print out and complete this form prior to your child's well visit if your insurance is the Cornell Program for Healthy Living (CPHL) from Aetna.  
Family Medicine Associates
8 Brentwood Drive
Ithaca, New York 14850
Phone:  607-277-4341
Fax:  607-216-0918
209 W. State Street, Ithaca, New York 14850
Phone: 607-277-4341
Fax: 607-216-0918
Family Medicine
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Useful Forms for New and Established Patients