Patient Information / Patient Forms & Surveys

Patient Registration Forms

For the convenience of our patients, forms are available on this web site. This will save time when you or a family member come in for an appointment, and eliminate any anxiety a person may have about filling out forms in the waiting room. Simply print out the appropriate forms, fill them out, and bring them with you when you come in.

If you have any questions about which forms you will need to complete, please call Mariellen Payne at 717.581.4814 for an explanation.

Click links below to view Patient Registration Forms.

Patient Demographics

Medical Information

Appendix for Back and Neck Problems

Authorization to Disclose Health Information (English)

Authorization to Disclose Health Information (Spanish)

You will need Adobe Acrobat Reader to view the forms. Click here to download Acrobat Reader.

Online Surveys
Click here for Online Surveys.