Online Registration Form

Patient Registration Form
Emergency Contact:
Patient Notice
If an individual or a patient at any time (regardless of disability, gender, national origin, race, religion, age, color, or of any other legally protected status) becomes loud, aggressive, cusses, or threatens an employee or other individual, they will be asked to leave the premises. We will discharge any patient that has acted in any manner that makes our employees or other patients feel threatened or in danger.

Authorization for Release of Information to Family Members
Many of our patients allow family members such as their spouse, parents or others to call and request medical or billing information. Under the requirements of HIPAA we are not allowed to give this information to anyone without the patient’s consent. If you wish to have your medical or billing information released to family members you must sign this form. Signing this form will only give information to family members indicated below.
Patient Information

Acknowledgement of Provider Standards
1. Controlled Substances
  • Chronic use of benzodiazepines and narcotics will not be managed by this provider for reasons unrelated to end-of-life / end stage disease management. 30 day prescriptions are provided on a case-by-case basis. No prescriptions for controlled substances, including but not limited to benzodiazepines, stimulants, and narcotics will be provided on a first visit.
2. Behavior
  • Physical and verbal abuse of the staff IS NOT TOLERATED. This includes, but is not limited, to physical and verbal assault. Yelling and swearing at staff will result in immediate dismissal from this provider.
3. Paperwork / Form Completion
  • Paperwork brought to the office on the same day can be picked up the week following your appointment. It will not be completed at the time of your visit with the exception for school forms for children. If paperwork is needed quickly you may bring it to the office a minimum of 4 days before your appointment for review.
  • Patient is responsible for filling in out the patient registration packet and fully completing it 15 minutes before their appointment. If paperwork is not fully completed on time, then the appointment will be rescheduled.
  • Disability examinations are not completed by this provider.
  • Letters for emotional support animals will not be provided.
  • Patients that are 10 minutes late to their appointment, and there no appointments available at that time, will be rescheduled for another day.
4. Attendance Policy:
  • Failure to provide a 24-hour notice of cancellation will result in a $25 Fee that is non-covered by your insurance company. You will bare all Financial Responsibility for this fee. If you have 3 No shows or last-minute Cancelations may result in Dismissal from our practice.
We are committed to providing you with the best possible medical care. If you have medical insurance, we would like to help you receive the maximum allowable benefits. In order to achieve this goal, we will need your assistance and understanding of our financial policies. Please carefully review this information and tick the boxes to agree.
Current insurance cards must be presented to the office at each visit. Any changes to personal information must be given to the office immediately.

Effective 6/6/2019, Comfort Care Family Practice will not prescribe medication for Chronic Pain Management. DEA regulations have made it difficult for primary care provides to manage pain that may require controlled substance prescriptions. Comfort Care Family Practice has primary care providers with the ability to treat many of your medical issues: however, some may require the care of a specialist. Our Providers will determine a course of care and a referral will be sent out. Comfort Care staff will refer you to pain management for your needs. Please note, it is then your responsibility to call that provider, confirm acceptance of your insurance and to make an appointment. When your appointment is made, call us back and we will refill your medication one time to last you through your appointment and up to 2 weeks with pain management. If you miss your appointment or reschedule your appointment with pain management, we will not refill your medication. There are a few requirements for the Colorado Clinic. You need to show up to the appointment 30 minutes prior for paperwork and prescreening. They will create a plan of action on the first visit and will not prescribe medications on the first visit. Patients are required to provide a UA drug screen at the visit. Patients cannot test positive for marijuana or other hard drugs.
Rest assured that Comfort Care Family Practice staff and providers want to help you on your quest to wellness and good health.


List your prescribed drugs and over-the-counter drugs, such as vitamins and inhalers
Allergies to medications

All Questions Contained In This Questionnaire Are Optional And Will Be Kept Strictly Confidential.

Personal Safety


Grandmother [Maternal]
Grandfather [Maternal]
Grandmother [Paternal]
Grandfather [Paternal]


Women Only


Men Only