Patient Forms and Documents

New Patient Registration Form

Medical History Form

Consent for Treatment Form

HIPAA Privacy Policy Acknowledgment

Financial Agreement Form

Authorization to Release Medical Records

Medication and Allergy Form

Preventive Care and Immunization History Form

Telehealth Consent Form

Patient Communication Preferences Form

Insurance

At Samara Primary Care Clinic, we strive to make healthcare accessible by partnering with a wide range of insurance providers. We accept most major insurance plans to ensure our patients receive the care they need with minimal out-of-pocket costs.

We Accept