Online Patient Forms

Prepare for your visit

Streamline your experience and ensure all your information is ready for discussion. Simply select the forms you need below and bring the completed documents to your appointment or e-mail them to us from our contact form.

  • Informed Consent Medical Form

    This form ensures you understand and agree to the proposed medical treatments and their potential risks and benefits.

    Open
    The image contains an informed consent document for Dr. Todd LePine's Functional Medicine practice, explaining the principles of Functional Medicine, its focus on personalized patient care, and its methods of addressing disease causes.

  • Patient Privacy Form

    Your privacy is our priority; this form outlines how your medical information is protected and shared.

    Open
    Privacy notice from Dr. Todd LePine's Functional Medicine practice detailing patient rights regarding medical information, such as accessing and correcting records, requesting confidential communication, limiting information sharing, obtaining a privacy notice copy, assigning representation, and filing complaints about privacy violations.

  • Medicare Private Contract Form

    DO NOT fill this out unless you have Medicare. This form outlines the agreement for private payment of medical services not billed through Medicare.

    Open
    Medicare Private Contract with Dr. Todd LePine, located at 292 Main Street, Suite #5, Great Barrington, MA 01230. The contract, complying with 42 U.S.C. §1395a and 42 C.F.R. § 405, details terms for the beneficiary's engagement and its effective and expiration dates.

  • MSQ Form

    This form helps assess your current health by identifying and tracking symptoms to guide personalized care. Please e-mail to info@drlepine.com once completed.

    Download
    Multiple Symptom Questionnaire with columns for different symptoms to be rated 0-4, covering areas like digestive tract, head, mouth/throat, heart, ears, joints/muscles, lungs, emotions, energy, mind, eyes, nose, skin, weight, and other. Fields for name, date of birth, address, email, and date are also included.

  • Modern Medicine the Old Fashioned Way

    Download the story of Dr LePine’s beginnings as a country doctor in the town of Stockbridge in the Berkshires

    Download
    Flyer for Stockbridge Family Medicine introducing a new doctor. It mentions the practice's location on West Main Street, highlights the motto "modern medicine the old fashioned way," and includes information about the doctor's background, education, and residency. The flyer also mentions the doctor's family and practice approach, emphasizing personal attention and house calls. There is a portrait of the doctor included in the flyer.