501 Airport Road, Rifle, Colorado 81650 | 970-625-1510 | Contact Information Facebook Twitter YouTube Patient Portal >

All forms are in Downloadable Printable PDF format.

Grand River Health Medical Records (Health Information Management)

Release of Medical Information

Fax  to 970.625.2752

Phone: 970.625.6412

Please print and fill out to bring with you to your next appointment

English

  1. Clinic New Patient Forms English
  2. HIPPA
  3. Clinic Medical Records Release
  4. Dr Krauth New Patient Forms English
  5. General Surgery New Patient Form
  6. Child History Questionnaire English
  7. Orthopaedic New Patient Forms
  8. ENT Intake form English
  9. Womens Health Questionnaire.pdf
  10. Consent to treat a Minor
  11. Mens Health Questionnaire
  12. CIIS questions
  13. Caputo Wound Care Intake Form
  14. Podiatric New Patient Form
  15. Sports Clearance Exam Form
  16. Rehab Balance Confidence Scale Form
  17. Rehab Dizziness Handicap Inventory
  18. Rehab Headache Disability Form
  19. Rehab LEFS Form
  20. Rehab Low Back Pain Form
  21. Rehab Neck Disability Form
  22. Rehab Pain Sheet
  23. Rehab QuickDash Form
 Spanish

  1. Formularios para pacientes nuevos en la clínica
  2. HIPAA
  3. Divulgación de expdientes médicos de la clínica
  4. Formularios para pacientes nuevos del Dr Krauth
  5. Pacientes nuevos de cirugía general
  6. Cuestionario del historial del niños
  7. Formularios para pacientes nuevos de ortopedia
  8. Formulario de ORL
  9. Cuestionario de salud femenina
  10. Consentimiento para tratamiento de menores
  11. Cuestionario de salud masculina
  12. Preguntas del SIIC
  13. Tratamiento de heridas del Dr Caputo
  14. Cuestionario de la Escala de Equilibrio
  15. IDM
  16. Cuestionario del Dolor de Cabeza
  17. Cuestionario de las Extremidades Inferiores
  18. Cuestionario del Dolor Lumbar
  19. Cuestionario del Discapacidad de Cuello
  20. Cuestionario del Dolor
  21. Cuestionario de QuickDash

 

Events Calendar

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Wed 09

Baby and Me

October 9 @ 10:00 am - 12:00 pm
Mon 14

Cooking Matters

October 14 @ 6:00 pm - 8:00 pm
Wed 16

Baby and Me

October 16 @ 10:00 am - 12:00 pm
Mon 21

Cooking Matters

October 21 @ 6:00 pm - 8:00 pm
Wed 23

Baby and Me

October 23 @ 10:00 am - 12:00 pm

Grand River News

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