Forms — The Carolina Center for Integrative Medicine

A member of our staff will be notified when you submit a form from one of the links below.

New Patient Forms Combined

Once your New Patient Appointment has been scheduled, click here to fill out the remaining forms.

Lyme Disease Form

Click here to fill out our comprehensive Lyme Disease Questionnaire.

Medical Records Request Form

Click here to have our office send your medical records to another provider.

Colon Hydrotherapy Screening Form

Click here to fill out a Colon Hydrotherapy Screening form.

HIPPA Privacy Authorization Form

Click here to authorize the release of your medical information and test results to someone else (like a family member).

Health History Form

Click here to fill out our comprehensive Health History Form.

New Patient Registration Form

Click here to fill out our New Patient Registration Form

Emergency Contact Form

Click here to provide your emergency contact’s information.

Pharmacy Form

Click here to provide your pharmacy’s information.

Insurance Form

Click here to provide your insurance information.

Transfer Medical Records to CCIM Form (Printable)

Click here for a form you can sign, print and send to another medical provider to request your records be sent to our office.