• OUR PROVIDERS
  • Carl Brown, PA
  • Adam Greathouse, MD
  • Janet Hulbert, ANP
  • Patricia Johnson, DO
  • Laura Johnson, DO
  • Glen Jones, PA
  • Sharon Lemmons, MD
  • Pedro Perez, MD
  • Don Smith, PA

DIMOND MEDICAL CLINIC
907 341-7757

300 East Dimond Blvd., Ste. 12
Anchorage, AK 99515
M-F: 9 a.m.—8 p.m.
Sat.:10 a.m.—6 p.m.



WASILLA MEDICAL CLINIC
907 373-6055

1700 E. Parks Hwy., #200
Wasilla, AK 99654
M-F: 10 a.m.—9 p.m.
Sat.: 10 a.m.—6 p.m.



LAKE OTIS MEDICAL CLINIC
907-561-7757

4001 Lake Otis Pkwy., Ste. 100
Anchorage, AK 99508
M-F: 9 a.m.—6 p.m.

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Forms


If you are a new patient coming to see us and want to print and fill out the forms prior to visiting us, please click on each link to open each form. These forms are also available at our clinics; you do not have to print them out beforehand.

 

If you do not have Adobe PDF Reader, click here and download your free copy (to read the forms).
Please note that some of these files are large and may take some time to open.

 

 

ALASKA MEDICAL CLINICS FORMS:

    New Patient Information Form (1 page)
    AMC Billing Policy (1 page)

    Report of Medical History Form (2 pages)
    AMC Notice of Privacy, Consent, and HIPPA (1 page)
    AMC Authorization and Consent to Treat a Minor
    AMC Notice of Privacy Practices (2 page HIPPA information)
    AMC Authorization to Disclose Medical Information


SCHOOL DISTRICT FORMS:

    Alaska School Activities Association Health Information Form (School Physicals) (2 pages, 1 for parents, 1 for physican) or see this link: www.asaa.org Mat-Su School Physical Information

    Form & Mat-Su Schools Athletic/Activities Registration Form
    Anchorage School District Physical Exam Form for School Entry
    Anchorage School District Activities/Athletics Form


STATE OF ALASKA FORMS:

    State of Alaska Consent for HIV Testing (PDF)