Patient Forms

The online submission process requires that you answer confidential health information that is needed to complete your request and shall only be utilized for your request. Your information will be secured by encryption software. While unlikely, it is still possible that this information could be intercepted by non-authorized individuals engaging in illegal internet activities. If you electronically submit a completed form or any other information to Reagan Medical Center, LLC through this website, you agree that you do so at your own choice and risk, and that you assume all responsibility for any liability arising from such electronic submission and from any errors or omissions in the data you provide. You agree to release and hold Reagan Medical Center, LLC and its affiliates (including its directors, officers, employees, shareholders, agents and representatives) harmless from any and all liability or cause of action arising from the interception, access or use by a third party of an information submitted electronically by you through this website and from any errors or omissions in the data you provide. Additionally, the provision of any information to Reagan Medical Center, LLC by you through this website, including any form / forms, does not create or constitute any relationship between you and Reagan Medical Center, LLC, its affiliates, or any physicians or its staff, to which any privilege may attach. By selecting the "I Accept" button, you are signing this Agreement electronically. You also agree your electronic signature with the use of mouse, keypad or other methods is the legal equivalent of your manual signature on the different forms which you might submit electronically online.

The online submission process requires that you answer confidential health information that is needed to complete your request and shall only be utilized for your request. Your information will be secured by encryption software. While unlikely, it is still possible that this information could be intercepted by non-authorized individuals engaging in illegal internet activities. If you electronically submit a completed form or any other information to Reagan Medical Center, LLC through this website, you agree that you do so at your own choice and risk, and that you assume all responsibility for any liability arising from such electronic submission and from any errors or omissions in the data you provide. You agree to release and hold Reagan Medical Center, LLC and its affiliates (including its directors, officers, employees, shareholders, agents and representatives) harmless from any and all liability or cause of action arising from the interception, access or use by a third party of an information submitted electronically by you through this website and from any errors or omissions in the data you provide. Additionally, the provision of any information to Reagan Medical Center, LLC by you through this website, including any form / forms, does not create or constitute any relationship between you and Reagan Medical Center, LLC, its affiliates, or any physicians or its staff, to which any privilege may attach. By selecting the "I Accept" button, you are signing this Agreement electronically. You also agree your electronic signature with the use of mouse, keypad or other methods is the legal equivalent of your manual signature on the different forms which you might submit electronically online.

The online submission process requires that you answer confidential health information that is needed to complete your request and shall only be utilized for your request. Your information will be secured by encryption software. While unlikely, it is still possible that this information could be intercepted by non-authorized individuals engaging in illegal internet activities. If you electronically submit a completed form or any other information to Reagan Medical Center, LLC through this website, you agree that you do so at your own choice and risk, and that you assume all responsibility for any liability arising from such electronic submission and from any errors or omissions in the data you provide. You agree to release and hold Reagan Medical Center, LLC and its affiliates (including its directors, officers, employees, shareholders, agents and representatives) harmless from any and all liability or cause of action arising from the interception, access or use by a third party of an information submitted electronically by you through this website and from any errors or omissions in the data you provide. Additionally, the provision of any information to Reagan Medical Center, LLC by you through this website, including any form / forms, does not create or constitute any relationship between you and Reagan Medical Center, LLC, its affiliates, or any physicians or its staff, to which any privilege may attach. By selecting the "I Accept" button, you are signing this Agreement electronically. You also agree your electronic signature with the use of mouse, keypad or other methods is the legal equivalent of your manual signature on the different forms which you might submit electronically online.

The online submission process requires that you answer confidential health information that is needed to complete your request and shall only be utilized for your request. Your information will be secured by encryption software. While unlikely, it is still possible that this information could be intercepted by non-authorized individuals engaging in illegal internet activities. If you electronically submit a completed form or any other information to Reagan Medical Center, LLC through this website, you agree that you do so at your own choice and risk, and that you assume all responsibility for any liability arising from such electronic submission and from any errors or omissions in the data you provide. You agree to release and hold Reagan Medical Center, LLC and its affiliates (including its directors, officers, employees, shareholders, agents and representatives) harmless from any and all liability or cause of action arising from the interception, access or use by a third party of an information submitted electronically by you through this website and from any errors or omissions in the data you provide. Additionally, the provision of any information to Reagan Medical Center, LLC by you through this website, including any form / forms, does not create or constitute any relationship between you and Reagan Medical Center, LLC, its affiliates, or any physicians or its staff, to which any privilege may attach. By selecting the "I Accept" button, you are signing this Agreement electronically. You also agree your electronic signature with the use of mouse, keypad or other methods is the legal equivalent of your manual signature on the different forms which you might submit electronically online.

The online submission process requires that you answer confidential health information that is needed to complete your request and shall only be utilized for your request. Your information will be secured by encryption software. While unlikely, it is still possible that this information could be intercepted by non-authorized individuals engaging in illegal internet activities. If you electronically submit a completed form or any other information to Reagan Medical Center, LLC through this website, you agree that you do so at your own choice and risk, and that you assume all responsibility for any liability arising from such electronic submission and from any errors or omissions in the data you provide. You agree to release and hold Reagan Medical Center, LLC and its affiliates (including its directors, officers, employees, shareholders, agents and representatives) harmless from any and all liability or cause of action arising from the interception, access or use by a third party of an information submitted electronically by you through this website and from any errors or omissions in the data you provide. Additionally, the provision of any information to Reagan Medical Center, LLC by you through this website, including any form / forms, does not create or constitute any relationship between you and Reagan Medical Center, LLC, its affiliates, or any physicians or its staff, to which any privilege may attach. By selecting the "I Accept" button, you are signing this Agreement electronically. You also agree your electronic signature with the use of mouse, keypad or other methods is the legal equivalent of your manual signature on the different forms which you might submit electronically online.

The online submission process requires that you answer confidential health information that is needed to complete your request and shall only be utilized for your request. Your information will be secured by encryption software. While unlikely, it is still possible that this information could be intercepted by non-authorized individuals engaging in illegal internet activities. If you electronically submit a completed form or any other information to Reagan Medical Center, LLC through this website, you agree that you do so at your own choice and risk, and that you assume all responsibility for any liability arising from such electronic submission and from any errors or omissions in the data you provide. You agree to release and hold Reagan Medical Center, LLC and its affiliates (including its directors, officers, employees, shareholders, agents and representatives) harmless from any and all liability or cause of action arising from the interception, access or use by a third party of an information submitted electronically by you through this website and from any errors or omissions in the data you provide. Additionally, the provision of any information to Reagan Medical Center, LLC by you through this website, including any form / forms, does not create or constitute any relationship between you and Reagan Medical Center, LLC, its affiliates, or any physicians or its staff, to which any privilege may attach. By selecting the "I Accept" button, you are signing this Agreement electronically. You also agree your electronic signature with the use of mouse, keypad or other methods is the legal equivalent of your manual signature on the different forms which you might submit electronically online.

The online submission process requires that you answer confidential health information that is needed to complete your request and shall only be utilized for your request. Your information will be secured by encryption software. While unlikely, it is still possible that this information could be intercepted by non-authorized individuals engaging in illegal internet activities. If you electronically submit a completed form or any other information to Reagan Medical Center, LLC through this website, you agree that you do so at your own choice and risk, and that you assume all responsibility for any liability arising from such electronic submission and from any errors or omissions in the data you provide. You agree to release and hold Reagan Medical Center, LLC and its affiliates (including its directors, officers, employees, shareholders, agents and representatives) harmless from any and all liability or cause of action arising from the interception, access or use by a third party of an information submitted electronically by you through this website and from any errors or omissions in the data you provide. Additionally, the provision of any information to Reagan Medical Center, LLC by you through this website, including any form / forms, does not create or constitute any relationship between you and Reagan Medical Center, LLC, its affiliates, or any physicians or its staff, to which any privilege may attach. By selecting the "I Accept" button, you are signing this Agreement electronically. You also agree your electronic signature with the use of mouse, keypad or other methods is the legal equivalent of your manual signature on the different forms which you might submit electronically online.

The online submission process requires that you answer confidential health information that is needed to complete your request and shall only be utilized for your request. Your information will be secured by encryption software. While unlikely, it is still possible that this information could be intercepted by non-authorized individuals engaging in illegal internet activities. If you electronically submit a completed form or any other information to Reagan Medical Center, LLC through this website, you agree that you do so at your own choice and risk, and that you assume all responsibility for any liability arising from such electronic submission and from any errors or omissions in the data you provide. You agree to release and hold Reagan Medical Center, LLC and its affiliates (including its directors, officers, employees, shareholders, agents and representatives) harmless from any and all liability or cause of action arising from the interception, access or use by a third party of an information submitted electronically by you through this website and from any errors or omissions in the data you provide. Additionally, the provision of any information to Reagan Medical Center, LLC by you through this website, including any form / forms, does not create or constitute any relationship between you and Reagan Medical Center, LLC, its affiliates, or any physicians or its staff, to which any privilege may attach. By selecting the "I Accept" button, you are signing this Agreement electronically. You also agree your electronic signature with the use of mouse, keypad or other methods is the legal equivalent of your manual signature on the different forms which you might submit electronically online.

The online submission process requires that you answer confidential health information that is needed to complete your request and shall only be utilized for your request. Your information will be secured by encryption software. While unlikely, it is still possible that this information could be intercepted by non-authorized individuals engaging in illegal internet activities. If you electronically submit a completed form or any other information to Reagan Medical Center, LLC through this website, you agree that you do so at your own choice and risk, and that you assume all responsibility for any liability arising from such electronic submission and from any errors or omissions in the data you provide. You agree to release and hold Reagan Medical Center, LLC and its affiliates (including its directors, officers, employees, shareholders, agents and representatives) harmless from any and all liability or cause of action arising from the interception, access or use by a third party of an information submitted electronically by you through this website and from any errors or omissions in the data you provide. Additionally, the provision of any information to Reagan Medical Center, LLC by you through this website, including any form / forms, does not create or constitute any relationship between you and Reagan Medical Center, LLC, its affiliates, or any physicians or its staff, to which any privilege may attach. By selecting the "I Accept" button, you are signing this Agreement electronically. You also agree your electronic signature with the use of mouse, keypad or other methods is the legal equivalent of your manual signature on the different forms which you might submit electronically online.

The online submission process requires that you answer confidential health information that is needed to complete your request and shall only be utilized for your request. Your information will be secured by encryption software. While unlikely, it is still possible that this information could be intercepted by non-authorized individuals engaging in illegal internet activities. If you electronically submit a completed form or any other information to Reagan Medical Center, LLC through this website, you agree that you do so at your own choice and risk, and that you assume all responsibility for any liability arising from such electronic submission and from any errors or omissions in the data you provide. You agree to release and hold Reagan Medical Center, LLC and its affiliates (including its directors, officers, employees, shareholders, agents and representatives) harmless from any and all liability or cause of action arising from the interception, access or use by a third party of an information submitted electronically by you through this website and from any errors or omissions in the data you provide. Additionally, the provision of any information to Reagan Medical Center, LLC by you through this website, including any form / forms, does not create or constitute any relationship between you and Reagan Medical Center, LLC, its affiliates, or any physicians or its staff, to which any privilege may attach. By selecting the "I Accept" button, you are signing this Agreement electronically. You also agree your electronic signature with the use of mouse, keypad or other methods is the legal equivalent of your manual signature on the different forms which you might submit electronically online.

The online submission process requires that you answer confidential health information that is needed to complete your request and shall only be utilized for your request. Your information will be secured by encryption software. While unlikely, it is still possible that this information could be intercepted by non-authorized individuals engaging in illegal internet activities. If you electronically submit a completed form or any other information to Reagan Medical Center, LLC through this website, you agree that you do so at your own choice and risk, and that you assume all responsibility for any liability arising from such electronic submission and from any errors or omissions in the data you provide. You agree to release and hold Reagan Medical Center, LLC and its affiliates (including its directors, officers, employees, shareholders, agents and representatives) harmless from any and all liability or cause of action arising from the interception, access or use by a third party of an information submitted electronically by you through this website and from any errors or omissions in the data you provide. Additionally, the provision of any information to Reagan Medical Center, LLC by you through this website, including any form / forms, does not create or constitute any relationship between you and Reagan Medical Center, LLC, its affiliates, or any physicians or its staff, to which any privilege may attach. By selecting the "I Accept" button, you are signing this Agreement electronically. You also agree your electronic signature with the use of mouse, keypad or other methods is the legal equivalent of your manual signature on the different forms which you might submit electronically online.

The online submission process requires that you answer confidential health information that is needed to complete your request and shall only be utilized for your request. Your information will be secured by encryption software. While unlikely, it is still possible that this information could be intercepted by non-authorized individuals engaging in illegal internet activities. If you electronically submit a completed form or any other information to Reagan Medical Center, LLC through this website, you agree that you do so at your own choice and risk, and that you assume all responsibility for any liability arising from such electronic submission and from any errors or omissions in the data you provide. You agree to release and hold Reagan Medical Center, LLC and its affiliates (including its directors, officers, employees, shareholders, agents and representatives) harmless from any and all liability or cause of action arising from the interception, access or use by a third party of an information submitted electronically by you through this website and from any errors or omissions in the data you provide. Additionally, the provision of any information to Reagan Medical Center, LLC by you through this website, including any form / forms, does not create or constitute any relationship between you and Reagan Medical Center, LLC, its affiliates, or any physicians or its staff, to which any privilege may attach. By selecting the "I Accept" button, you are signing this Agreement electronically. You also agree your electronic signature with the use of mouse, keypad or other methods is the legal equivalent of your manual signature on the different forms which you might submit electronically online.

The online submission process requires that you answer confidential health information that is needed to complete your request and shall only be utilized for your request. Your information will be secured by encryption software. While unlikely, it is still possible that this information could be intercepted by non-authorized individuals engaging in illegal internet activities. If you electronically submit a completed form or any other information to Reagan Medical Center, LLC through this website, you agree that you do so at your own choice and risk, and that you assume all responsibility for any liability arising from such electronic submission and from any errors or omissions in the data you provide. You agree to release and hold Reagan Medical Center, LLC and its affiliates (including its directors, officers, employees, shareholders, agents and representatives) harmless from any and all liability or cause of action arising from the interception, access or use by a third party of an information submitted electronically by you through this website and from any errors or omissions in the data you provide. Additionally, the provision of any information to Reagan Medical Center, LLC by you through this website, including any form / forms, does not create or constitute any relationship between you and Reagan Medical Center, LLC, its affiliates, or any physicians or its staff, to which any privilege may attach. By selecting the "I Accept" button, you are signing this Agreement electronically. You also agree your electronic signature with the use of mouse, keypad or other methods is the legal equivalent of your manual signature on the different forms which you might submit electronically online.

The online submission process requires that you answer confidential health information that is needed to complete your request and shall only be utilized for your request. Your information will be secured by encryption software. While unlikely, it is still possible that this information could be intercepted by non-authorized individuals engaging in illegal internet activities. If you electronically submit a completed form or any other information to Reagan Medical Center, LLC through this website, you agree that you do so at your own choice and risk, and that you assume all responsibility for any liability arising from such electronic submission and from any errors or omissions in the data you provide. You agree to release and hold Reagan Medical Center, LLC and its affiliates (including its directors, officers, employees, shareholders, agents and representatives) harmless from any and all liability or cause of action arising from the interception, access or use by a third party of an information submitted electronically by you through this website and from any errors or omissions in the data you provide. Additionally, the provision of any information to Reagan Medical Center, LLC by you through this website, including any form / forms, does not create or constitute any relationship between you and Reagan Medical Center, LLC, its affiliates, or any physicians or its staff, to which any privilege may attach. By selecting the "I Accept" button, you are signing this Agreement electronically. You also agree your electronic signature with the use of mouse, keypad or other methods is the legal equivalent of your manual signature on the different forms which you might submit electronically online.

The online submission process requires that you answer confidential health information that is needed to complete your request and shall only be utilized for your request. Your information will be secured by encryption software. While unlikely, it is still possible that this information could be intercepted by non-authorized individuals engaging in illegal internet activities. If you electronically submit a completed form or any other information to Reagan Medical Center, LLC through this website, you agree that you do so at your own choice and risk, and that you assume all responsibility for any liability arising from such electronic submission and from any errors or omissions in the data you provide. You agree to release and hold Reagan Medical Center, LLC and its affiliates (including its directors, officers, employees, shareholders, agents and representatives) harmless from any and all liability or cause of action arising from the interception, access or use by a third party of an information submitted electronically by you through this website and from any errors or omissions in the data you provide. Additionally, the provision of any information to Reagan Medical Center, LLC by you through this website, including any form / forms, does not create or constitute any relationship between you and Reagan Medical Center, LLC, its affiliates, or any physicians or its staff, to which any privilege may attach. By selecting the "I Accept" button, you are signing this Agreement electronically. You also agree your electronic signature with the use of mouse, keypad or other methods is the legal equivalent of your manual signature on the different forms which you might submit electronically online.

The online submission process requires that you answer confidential health information that is needed to complete your request and shall only be utilized for your request. Your information will be secured by encryption software. While unlikely, it is still possible that this information could be intercepted by non-authorized individuals engaging in illegal internet activities. If you electronically submit a completed form or any other information to Reagan Medical Center, LLC through this website, you agree that you do so at your own choice and risk, and that you assume all responsibility for any liability arising from such electronic submission and from any errors or omissions in the data you provide. You agree to release and hold Reagan Medical Center, LLC and its affiliates (including its directors, officers, employees, shareholders, agents and representatives) harmless from any and all liability or cause of action arising from the interception, access or use by a third party of an information submitted electronically by you through this website and from any errors or omissions in the data you provide. Additionally, the provision of any information to Reagan Medical Center, LLC by you through this website, including any form / forms, does not create or constitute any relationship between you and Reagan Medical Center, LLC, its affiliates, or any physicians or its staff, to which any privilege may attach. By selecting the "I Accept" button, you are signing this Agreement electronically. You also agree your electronic signature with the use of mouse, keypad or other methods is the legal equivalent of your manual signature on the different forms which you might submit electronically online.