Patient Forms

Please complete patient forms prior to your visit. Click on the link, download the form, print, complete, and bring the form with you to your next appointment. Filling out these forms before you come in for your first visit will assist us in expediting your appointment.

Standard Patient Forms

Notice of Privacy Policy Form

Authorization to Release Medical Information – Greenville

Authorization to Release Medical Information – Goldsboro

Authorization to Release Medical Information – Wilson

ECPC – Greenville New Patient Questionnaire 

ECUHPMC New Patient Questionnaire

Notice of Nondiscrimination & Accessibility Statement

Referral Form – Wilmington

Referral Form – Knightdale

Unifour Pain Treatment Center Patient Data Form – History

Unifour Pain Treatment Center Referring Provider Form – Hickory

Low Level Vision Patient Forms

Notice of Privacy Policy Form

Authorization to Release Medical Information – Greenville

Authorization to Release Medical Information – Goldsboro

Authorization to Release Medical Information – Wilson

ECPC – Greenville New Patient Questionnaire 

VPMC Long Form Pain Questionnaire 

Notice of Nondiscrimination & Accessibility Statement

Unifour Pain Treatment Center Patient Data Form

View Conditions Treated