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Patient Forms

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.

Massachusetts Health Care Proxy Form (pdf)

The Health Care Proxy is a simple legal document that allows you to name someone you know and trust to make health care decisions for you if, for any reason and at any time, you become unable to make or communicate those decisions.

Authorization for Verbal Disclosure of Health Information (pdf)

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.

Flexible Spending Medications Requests

Please read this notice about changes in over-the-counter medications if you have a Flexible Spending Account.

International Travel Planner (pdf)

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) (pdf)

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.

Blank Food Log (pdf)

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.

MyHealth Online

Through our patient portal you are able to:

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:

Authorization for Release of Information from Medical Records (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.

Authorization for Release of Radiology Information (pdf)

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).