PIEDMONT INTERNAL MEDICINE

Please bring the Patient Registration Form and the Patient History form for your first visit. The following forms are available online:

• Patient Registration Form
• Patient History Form
• Notice of Privacy Form
• Cancellation Form
• Pre-Sleep Studies Questionnaire
• Post-Sleep Studies Questionnaire
• PFT Information
• Credit Card Authorization Form*

*Please review this credit card authorization form below.
We have made it simple to type in your information online, save as a pdf and email to officemgr@pimpaid.com.

**This form is not compatible with the Firefox® Browser. We have made it easy for you to make a pdf. First click on link and download form. Then download the Acrobat software (see link below on this page) if you do not have. Next, save as a pdf and email to officemgr@pimpaid.com. Or if you prefer, you can print out, fill out, and bring with you to your appointment.

***Note: This credit card authorization form information will be shredded when the patient shows up for the appointment, and we will not keep it in the chart.

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