Martha Jefferson Medical Enterprises

Welcome to Martha Jefferson Medical Group. For your convenience and to expedite your registration process, please download and print the new registration forms here
	FIRST VISIT FORMS
		Registration Form and Financial Policy	Please complete the demographic form and insurance information.
		Adult History Form	Please complete the self-history form and bring it to your first visit along with a list of your medications.
		Pediatric Registration Forms	Parents/Guardians—Please complete all forms and bring them with you to your child’s first visit along with insurance information and any current medications.
		Spanish Registration Forms	Informacion del Paciente. Please complete this form along with the age-appropriate forms below.
		Spanish Pediatric Forms	Forma de Historia de Salud Pediátrica.
		Spanish Adult History Form	Historia Completa del Adulta de Salud.
		Authorization for Release of Information	For new patients transferring their care to Martha Jefferson Medical Group, please complete the Release of Information form to have your records sent to your new provider. Sending this form to your former provider prior to your appointment with your new doctor will help us to receive your pertinent medical records in time for your appointment.


	FOR PULMONOLOGY PATIENTS Please download and print the registration forms for Martha Jefferson Medical Associates. The history forms detailing your past medical history, and in particular the Respiratory Questionnaire will be important information for your first visit with Dr. Schult. Please bring your medications with you to your first visit also.
		Dr. Alexander Schult Packet
		Authorization for Release of Information

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