Please take a few minutes to print either the Adult Patient History Form (if this is your first visit), the Adult Patient History Follow-Up Form (if this is a subsequent visit), or the Pediatric Patient History Form and answer each question before your physical exam appointment or your child’s. If you are 65 or older, please also complete the Adult Patient Questionnaire Addendum. Your physician will review this information with you and all information will then be entered into our system as part of your permanent record.
The following forms are provided for your convenience. Some may be submitted on line while others must be printed and returned to our offices.
If this is an urgent request, please call our offices at 781-878-5200. If this is a medical emergency, please call 911 immediately.
This form is used to authorize the verbal communication of your care and treatment with an identified family member, friend or caregiver. The completed form should be mailed or faxed to the address/fax number noted at the top of the form. If you have any questions, please contact the Medical Records Department at 781-681-1630.
Please read this notice about changes in over-the-counter medications if you have a Flexible Spending Account.
This helpful planner is designed to help you keep track of immunizations, prescriptions and other vital travel information.
M-CHAT (Modified Checklist for Autism in Toddlers) is a screening tool designed to help identify developmental delays in toddlers between the ages of 18 and 36 months and is recommended by the American Academy of Pediatrics.
While M-CHAT does not allow your child’s physician to make a diagnosis of developmental delay, it can indicate if your child is at risk and should receive further evaluation.
At your child’s next check-up, we will ask you to complete the attached checklist; it will be collected by the nurse for the physician’s review.
Before your appointment with a Nutritionist and or Dietician, please print out and fill in this food log. Bring your completed log with you to the appointment.
Through our patient portal you are able to:
- Request a prescription renewal
- Request an appointment
- Request a referral from your primary care provider to a specialist
- Print school and camp forms
- Change address, phone, and email
- MyHealth Adult Proxy Access (pdf)
Proxy access allows you to use MyHealth Online to communicate with the doctor’s office of a family member or loved one regarding non-urgent matters. Access is granted once a signed paper authorization form has been completed and processed by the patient’s primary care site location.
- MyHealth Adolescent Access Form (pdf)
Adolescent access for MyHealth Online allows an adolescent patient between the ages of 13 to 18 to view components of their medical record and communicate with their physician’s office regarding non-urgent matters. The parent/legal guardian will also be able to view a limited portion of the adolescent’s medical record. In order to obtain access, both the parent/legal guardian and the adolescent must complete and sign the Adolescent Access Authorization Form. Adolescent Access is terminated when the patient or parent/legal guardian makes a written or online request to terminate access. At age 18 the patient will have full control of their MyHealth Online account and the parent/legal guardian access will be discontinued. Beyond the age of 18 the patient may still grant parent/legal guardian access by completing a MyHealth Online Adult Proxy Access form.
- MyHealth Pediatric Proxy Access (pdf)
Pediatric Proxy access for MyHealth Online allows you to securely communicate on behalf of a pediatric patient between the ages of newborn and 13 years of age. Access is automatically terminated on child’s 13th birthday.
Please Read Before Requesting a Copy of Your Records
To off-set the rising costs associated with producing medical record copies, it has become necessary to ask for payment before each request can be processed. Details are contained in these documents:
- Requesting a Copy of Your Medical Records for Personal Use (pdf)
- Requesting a Copy of Your Medical Records When Transferring Your Care (pdf)
Use this form if you require release of partial or full information from your medical records. This form requires a patient/parent and/or legal guardian’s signature and CANNOT be emailed to SSMC. Please print and complete this form and bring to the Medical Records Department at SSMC-Norwell for processing.
Use this form if you require release of images/reports from Radiology. This form requires a patient/parent and/or legal guardian’s signature; please print and complete this form and mail or fax to the Radiology department (781-681-9283).