Downloadable Forms for Patients of The Baton Rouge Clinic

For registration at The Baton Rouge Clinic, AMC

• PATIENT REGISTRATION FORM
• OPELOUSAS PATIENT REGISTRATION FORM
• URGENT CARE PATIENT REGISTRATION FORM
• BRC CREDIT POLICY

Release of Protected Health Information:

• HIPAA PRIVACY NOTICE
  • The HIPAA Privacy Notice describes how health information about you may be used and disclosed and how you can get access to this information.
• RELEASE FROM THE BATON ROUGE CLINIC, AMC
  • This form will allow you to release your records from The Baton Rouge Clinic, AMC to another organization or individual.
• RELEASE TO THE BATON ROUGE CLINIC, AMC
  • This form is used to request your records from another organization to be released to The Baton Rouge Clinic, AMC.
• RIGHT OF ACCESS
  • This form allows the authorized person of your choosing to access your records. (i.e. Giving spouse access to other spouse’s records, Son or daughter accessing parent’s records, etc.)

For the Release of Medical Records
Phone: (225) 246-9770
Fax: (225) 246-9209

These forms are part of a child’s comprehensive assessment for ADD/ADHD.

• NICHQ TEACHER ASSESSMENT
• NICHQ PARENT ASSESSMENT
• NICHQ TEACHER FOLLOW UP
• NICHQ PARENT FOLLOW UP

To read the MyChart Terms and Conditions of Use, please click here.

• MYCHART ADULT PROXY FORM
  • To request access to the MyChart record of an adult whose medical care you help manage, please complete this form.
• MYCHART TEEN PROXY FORM
  • To request full proxy access to the MyChart record of your teenage child, 15 to 17 years old, please complete this form.
• MYCHART CHILD PROXY FORM
  • To sign up for access to your child’s (aged 0-14 years) MyChart record, please complete both pages of this Child Proxy Form.

The completed form can be returned to your Primary Care Provider’s Office or faxed to (225) 246-9140.

Please print and bring these forms to your vaccine appointments.

• COVID-19 VACCINE CONSENT FORM
• FLU CONSENT FORM

Instructions for before and after procedures and brochure overview.

• COSMETIC SERVICES BROCHURE
• PRE-PROCEDURE BBL
• POST-PROCEDURE BBL
• PRE-PROCEDURE LASER HAIR REDUCTION/REMOVAL
• POST-PROCEDURE LASER HAIR REDUCTION/REMOVAL
• PRE-PROCEDURE MICRO LASER PEEL
• POST-PROCEDURE MICRO LASER PEEL
• PRE-PROCEDURE PROFRACTIONAL
• POST-PROCEDURE PROFRACTIONAL
• PRE-PROCEDURE SCLEROTHERAPY
• POST-PROCEDURE SCLEROTHERAPY

Surgery forms recommended by our doctors.

Breast Cancer:

• History Form
• Breast Cancer Risk Assessment Form

Sleep Medicine forms recommended by our doctors.

• SLEEP STUDY QUESTIONNAIRE
• APAP/BIPAP/ CPAP QUESTIONNAIRE
• REVIEW OF SYMPTOMS
• FUNCTIONAL OUTCOMES OF SLEEP QUESTIONNAIRE
• SLEEP DIARY

General forms as recommended by our doctors.

• BONE DENSITY QUESTIONNAIRE
• MAMMOGRAM QUESTIONNAIRE
• RESTLESS LEG SYNDROME

Questions, surveys, and authorization forms.

• MRI PATIENT INSTRUCTIONS
• MRI SCREENING HISTORY AND QUESTIONNAIRE FORM