Patient Forms
For your convenience, we have supplied our general patient forms below. If you wish, click on the links below, print, complete the forms, and bring them with you to your appointment. Printing them, filling them out and bringing them with you will allow us to attend to your medical needs more quickly than completing them upon your arrival.
NEW PATIENT INTAKE PACKAGE:
REGISTRATION FORM: CLICK HERE
NOTICE OF PRIVACY PRACTICES (HIPAA): CLICK HERE
PATIENT INFORMATION DISCLOSURE FORM: CLICK HERE
PATIENT QUESTIONNAIRE - ENGLISH: CLICK HERE
PATIENT QUESTIONNAIRE - ESPANOL: CLICK HERE
OTHER FORMS:
PATIENT BILL OF RIGHTS: CLICK HERE
MEDICAL RECORD RELEASE FORM: CLICK HERE
PATIENT COMPLAINT FORM: CLICK HERE
If, for some reason, you felt that the service you received was not satisfactory, please fill out our Patient Complaint Form online and email it to Mark Hammond (mhammond@whcccc.org) with the subject line "Patient Complaint." You can also call Mark to discuss your experience at 203.852.9525. If you prefer to mail the Patient Complaint Form, please download it and send it to:
CIRCLE CARE Center
c/o Mark Hammond
618 West Avenue
Norwalk, CT 06850