Chapel Hill Primary Care
New Patient Form Packet
Established Patient Annual Update Form

Dr. Karen Clark
Gynecology, Menopause and Women's Wellness
New Patient History Form
Annual Update

Susan Delaney, ND
Naturopathic Medicine
New Patient Form

Leslie Lotina, LCSW Counseling
Welcome Letter
New Client Form

Dr. Rachel Tesser
Triangle Ophthalmology
Triangle Ophthalmology Welcome Letter
New Patient Medical History Form
New Patient Medications Form
Insurance and Billing Information

Susan Wyler, MPH, RD, LDN
Triangle Nutritional Wellness
Initial Intake Form

Dr. Douglas A. Drossman
Drossman Gastroenterology, PLLC
New Patient Form

Medical Records Release Forms

To have medical records sent to or from a practice here at the Center, please print and fill out the medical records release form below corresponding to your provider's practice.  Please read the instructions on the release form carefully, noting any potential charges. Include as much information as possible to expedite requests. Drop off, mail, or fax completed forms. Our fax number is 919-929-7991. Please be aware that turnaround time can take a few weeks depending on the extent of the request and the protocol of the other offices involved.

Chapel Hill Primary Care
Karen Clark, MD, Gynecology, Women's Wellness & Menopause
Drossman Gastroenterology, Douglas Drossman, MD
Triangle Ophthalmology, PA, Rachel Tesser, MD.
Chapel Hill Functional Rehabilitation Clinic, P.A.
Ingrid Luo-Tseng, MD