Magnolia Medical Clinic

Patient Forms




Medical Records Release
New Patient Information Packet
If you need access to your medical records, first trying logging into the Patient Portal in which you have access to most of the information you may be searching for. If you cannot find what you need there, complete this Medical Records Request Form and return to the clinic in person. Please note, as of March 1, 2015, payment will be required for personal medical record requests.
Save some time by completing this packet and bringing it with you to your upcoming appointment. Print and complete the following:
Notice of Privacy Policy
This notice describes how medical information about you may be used and disclosed as a patient of Magnolia Medical Clinic.
Patient Information
Patient History
Clinic Policies
This sheet reviews some of the common clinic policies regarding appointments, prescriptions and more.
Authorization for Disclosure of Healthcare Information
This form allows you to specify whom we are allowed to disclose your medical information to - i.e. spouse, child, etc.