Patient Info & Forms
At UB Clinics, we want you to have the best possible experience. To expedite your visit, kindly print and complete the appropriate forms below and bring them with you to your appointment. In addition, feel free to review our Patient’s Bill of Rights below.
Complete the appropriate forms below and bring a copy with you to your appointment.
UB Clinic Intake Form
To be completed by all new UB Clinic patients except for Fones Dental Hygiene Clinic patients.
UB Acupuncture Patient Consent Form
Please complete if you are visiting the UB Acupuncture Clinic.
UB Chiropractic Patient Consent Form
Please complete if you are visiting the UB Chiropractic Clinic.
Fones Dental Hygiene Clinic Health History Form
Please complete if you are visiting the Fones Dental Hygiene Clinic.
UB Naturopathic Patient Consent Form
Please complete if you are visiting the UB Naturopathic Medicine Clinic.
- The patient has the right to considerate and respectful care.
- The patient has the right to and is encouraged to obtain from physicians and other direct care givers relevant, current, and understandable information concerning diagnosis, treatment, and prognosis. Patients have the right to know the identity of physicians, nurses, and others involved in their care, as well as those involved are students, residents, or other trainees.
- The patient has the right to make decisions about the plan of care prior to and during the course of treatment and to refuse a recommended treatment or plan of care to the extent permitted by law and to be informed of the medical consequences of this action.
- The patient has the right to have advance directive (such as a living will, health care proxy, or durable power of attorney for health care) concerning treatment or designating a surrogate decision maker with the expectation that the hospital will honor the intent of the directive to the extent permitted by law. Health care institutions must advise patients of their rights under state law and hospital policy to make informed medical choices, ask if the patient has an advance directive, and include that information in patient record.
- The patient has the right to every consideration of privacy. Case discussion, consultation, examination, and treatment should be conducted so as to protect each patient’s privacy.
- The patient has the right to expect that all communications and records pertaining to his/her care will be treated as confidential by a health care institution, except in cases such as suspected abuse and public health hazards when reporting is permitted or required by law.
- The patient has the right to review the records pertaining to his/her medical care and to have the information explained or interpreted as necessary, except when restricted by law.
- The patient has the right to expect that, within its capacity and policies, a health care institution will make reasonable response to the request of a patient for appropriate and medically indicated care and services. When medically appropriate and legally permissible, or when a patient has so requested, a patient may be transferred to another facility. The patient must also have the benefit of complete information and explanation concerning the need for, risk, benefits, and alternatives to such a transfer.
- The patient has the right to ask and be informed of the existence of business relationships among the hospital, educational institutions, other health care providers, or payers that may influence the patient’s treatment and care.
- The patient has the right to consent to or decline to participate in proposed research studies or human experimentation affecting care and treatment or requiring direct patient involvement, and to have those studies fully explained prior to consent.
- The patient has the right to expect reasonable continuity of care when appropriate and to be informed by physicians and other caregivers of available and realistic patient care options when hospital care is no longer appropriate.
- The patient has the right to be informed of health care policies and practices that relate to patient care, treatment, and responsibilities. The patient has the right to be informed of available resources for resolving disputes, grievances, and conflicts, such as ethic committees, patient representatives, or other mechanisms available in the institution. The patient has the right to be informed of the facility’s charges for services and available payment methods.