Patient Forms


 

Patient Forms for Check-in and Registration

Prepare for your A+ Total Care visit and speed your check-in process by completing required registration forms in advance. You can download and print patient forms to bring with you to A+ or submit your completed form by email.

For guidance in determining which forms you’ll need to fill out prior to your visit, look through our Patient FAQs page, call A+ Patient Services at 775-777-7587 or fill out and submit our online contact form for further assistance.


Submitting Forms

You can download, print, and fill out the forms to be deliver to us in-person at our clinic or send forms by email.

Hand-deliver or mail forms to: 976 Mountain City Hwy in Elko, 89801
Send completed forms by email

We are not accepting faxed forms at this time.


Patient Registration

New Patient Registration
Nuevo Reistro de Pacientes

Established Patient Registration
Registro de Pacientes Establecidos


Patient Authorization

Authorization to Release Medical Information
Autorización Para Divulgar Información Médica

Parental Authorization
Autorización de los Padres



Work-related Injury or Illness

Medical Authorization


Employee’s Claim for Compensation/Report of Initial Treatment–C4


Work-related Illness or Injury
Lesión o Enfermedad Relacionada con el Trabajo


Patient Surveys & Feedback

Patient Satisfaction Survey
Encuesta de Satisfacción del Paciente


WeCare Medical Discount Program Application

Learn about our WeCare Medical Discount Program or sign up to become a WeCare member and save on visits to our clinic year-round.


Employer Registration Forms

For a list of A+ OccMed registration forms for businesses wanting to send their employees for treatment at A Plus or to request on-site medical services, visit our Employer Forms page.

Location
A+ Total Care
976 Mountain City Highway
Elko, NV 89801
Phone: 775-238-4476
Fax: 775.738.9584
Office Hours

Get in touch

775-238-4476