Sacramento Colon & Rectal Surgery Medical Group, Inc.



If you are a new patient and you are accessing this page directly, you will find it beneficial to read the Office Visit page before you download the forms.

There are four forms that you need to fill out before your initial office visit. You can access the forms by clicking on the links below.

Patient Behavior Agreement

Chaperone Policy


Medical Questionnaire

Financial Policy

Patient Information Form

  • fillable PDF documents. You can fill the forms out on your computer or hand held device and print it. Once the form is filled, the data that you entered CAN be saved, you will then have to print it. You also have the option to print the blank forms and fill it in.

    The Patient Information form is used to gather information about your address, phone number, contacts and medical insurance. The Financial form has our financial policy, print 2 copies, one for your records and the other for our records, be sure to sign and date the form.

    The Patient Medical Questionnaire form is 5 pages long. Before you start filling out this form make sure that you have your medication list, a list of your previous surgical procedures, family history and a list of your allergies. We urge you to take the time to accurately list your medications with dosage as well as your previous surgical procedures. If you run out of space there is additional space at the end of the form.

    The Health Insurance Portability and Accountability Act of 1996 (HIPAA) form contains information about our practices to protect your privacy. Please keep the HIPAA form for your reference. Please sign and date the last page of the form and bring it in, as we need it for our records.