PH: 208.966.4087 | FAX:208.966.4031

1875 N Lakewood Dr., Suite 205, Coeur d'Alene, ID 83814

 
 

Forms - Jackie Wagner, NP-C

Family Practice by the Lake offers online forms for your convenience. Feel free to print any of these forms out for information or to fill out at your convenience before your first appointment. If you are a current patient, we encourage you to use our secure patient portal for individual information. If you have any questions about these forms, please give Family Practice by the Lake a call.


     
 

New Patient Information Sheet.pdf

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Consent to Treat.pdf

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Patient Responsibility Form.pdf

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Release of Health Information.pdf

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HIPAA Disclosure Form.pdf

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Notice of Health Information Privacy Practices.pdf

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Sports Physical Exam Form.pdf

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Blood Pressure Log.pdf
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Blood Sugar Log Sheets.pdf 



 
     
 

FAMILY PRACTICE
BY THE LAKE

1875 N Lakewood Dr.
Suite 205
Coeur d'Alene, ID 83814
---
Ph: 208.966.4087

 
 
 
 
 
 
 

1875 N Lakewood Dr.
Suite 205
Coeur d'Alene, ID 83814
---------------
PH: 208.966.4087
FAX: 208.966.4031

 

 

 

 

 

 

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