Resources for Patients

The following handouts are available to download and print. Completing necessary forms in advance and bringing them with you will help us keep your waiting time to a minimum.

All resources are available in PDF format.
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Medical Records
Medical Records Release Form
Medical Records Request Form
Trinity Center Resources
Policy on Advance Directives		Non-Participating Plans Pre-Payment Acknowledgment Form
Electronic Health Information Consent Form		Pharmacy/Lab Information
Electronic Health Information System Fact Sheet		Planning Advance Directives
Patient Demographic Form		Deaf & Hard-Of-Hearing Questionnaire
Financial Policies		Interpreter Consent Form
Referral Form for Testing		HIPAA Consent Form
Financial Acknowledgement Form		FAQ: Privacy and Security With Epic
HIPAA Form
Cardiology Resources
Stress Test Preparation Checklist
Gastroenterology Resources
Screening GI Procedure Information
Dr. Kummer's Patient Forms:	Dr. Laufer's Patient Forms:	Dr. Rajapaksa's Patient Forms:	Dr. Janec's Patient Forms:	Dr. Rosenberg's Patient Forms:	Dr. Mitchell Bernstein's Patient Forms:
HalfLytely® Preparation for Colonoscopy	Colonoscopy Preparation Instructions	Colonoscopy Preparation Instructions	Half-Lytely Preparation for Colonoscopy	MoviPrep Split Dose	Colonoscopy Preparation with Miralax
Preparation for Upper G.I. Endoscopy	Colonoscopy: Day of Procedure	2-day Colonoscopy Preparation Instructions	Moviprep Instructions #1- before 10am app	MoviPrep Evening Dose	Half-Lytely Preparation for Colonoscopy
Preparation for Sigmoidoscopy	Moviprep Instructions #1- before 10am app	Colonoscopy: Day of Procedure	Moviprep Instructions #2- after 10am app	Upper Endoscopy Instructions
Colonoscopy with MoviPrep Instructions	Moviprep Instructions #2- after 10am app	Upper Endoscopy Instructions	Colonoscopy Preparation with Dulcolax and Magnesium Citrate
Lactulose-Lactose-Fructulose-Fructase Breath Test Instructions	Extra Strength Instructions	Preparation for Colonoscopy with MoviPrep	Colonoscopy Preparation with Miralax
Colon Citrate form	OsmoPrep Colonoscopy Procedure	Colonoscopy Prep with Suprep
Urea Breath Test	Instrucciones para MoviPrep (En Español)
	Colonoscopy Prep with Suprep
Forms for Special Circumstances: Use only when directed by Dr. Kummer
PEG Preparation for Colonoscopy
Gynecology Resources
Pre-Admission Medical Evaluation From
Waiver for Non-covered Conscious Sedation- LEEP
Imaging Resources
Compact Disc Release Form
Internal Medicine
Dr. Carron's Patient Forms:
Immigration Registration Form
INS Form
Immigration Visit Information
Orthopaedics
Dr. Cardone's Patient Forms:
Patient Intake Form