Hampstead Family Medicine

and

Burgaw Medical Center- (910) 259-3377


Hampstead Family Medicine- (910) 803-0340

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Burgaw Medical Center​  


New Patient Form: This form has you personal information and health history as well as family history. It must be filled out prior to your visit. 



HIPAA Form: This form is your Acknowledgement of HIPAA rights and responsibilities. Please List only family member you wish to have access and obtain your health care information. 


Office Policy Agreement: This form outlines the rules, guidelines and expectations of our facilities. This form requires a signature of your acknowledgement of these rules and guidelines and how they pertain to you as a patient.


​Notice of Privacy Practice: This form is to inform you that all information obtained by our facility for each and every patient is confidential. This requires a signature of acknowledgement 

 





New Patient Forms 

The forms below are the required documents to establish care at our facilities. Each office may require additional forms to be filled out at your appointment, at the providers discretion