Online Forms

David W. Frasure DC PA offers our patient form(s) online so you can complete it in the convenience of your own home or office.  We offer these in two formats:  AdobeAcrobat and Microsoft Word. 

• If you do not already have AdobeReader® installed on your computer, Click Here to download.
• Download the necessary form(s) and send us your completed forms either via Fax (850-727-0025), Email (drfrasure@yahoo.com) or bring them with you to your appointment.  

New Patient Forms

There are three (3) required forms for new patients to complete. 

1) New Patient Health History Form (Microsoft Word)       

    New Patient Health History Form (Adobe Acrobat)

2) Financial Responsibility Form (Microsoft Word)              

    Financial Responsibility Form (Adobe Acrobat)

3) HIPPA Form (Microsoft Word)                                      

    HIPPA Form (Adobe Acrobat)

If we are treating a minor child, we will need an Authorization to Treat a Minor Child Form completed by a parent or legal guardian.

Authorization to Treat a Minor Child (Microsoft Word)    

Authorization to Treat Minor Child (Adobe Acrobat)

 Release of Patient Information

If you need to obtain a copy of your patient records located at our office for your use or for another doctor's use, download this form, complete, and fax/bring to our office.

Release of patient records to a third party (Microsoft Word)

Release of patient records to a third party (AdobeAcrobat)

If you need to obtain a copy of your patient records located at ANOTHER DOCTOR'S office for our use, download this form, complete, and fax/bring to the other doctor.

Release of your records to US (Microsoft Word)

Release of your records to US (AdobeAcrobat)

If you have any questions, give us a call.

Member Wellness Registration Form - Optional

This form can be filled out to register for access to the member wellness section of our website. You can also sign up for our monthly newsletter to keep up on current health issues and news and events in our office. You can print it out and bring it in to our office or Click Here to register online! The online newsletter sign-up is also on the right. We look forward to making your experience with our office and website more interactive and rewarding!