Forms

New patient forms, COVID test forms and more

New Patient Paperwork

All new patients must fill out the New Patient Paperwork before being seen. Patients 17 and under will need to have these forms filled out by a parent or guardian.

 

New Patient Paperwork

 

Minor Consent to Treat

Complete this form to authorize your minor child (age 17 and under) to be seen with another adult present or by his/her self. This form must be completed in the presence of a Capstone Family Medicine employee unless it is notarized.

 

Minor Consent to Treat

Medicare Forms

Medicare Annual Wellness Visit

At Capstone Clinic, we prioritize your health and well-being. As part of our commitment to providing comprehensive care, we invite you to schedule your Medicare Annual Wellness Visit.

What is a Medicare Annual Wellness Visit (AWV)?
A Medicare Annual Wellness Visit is a yearly appointment designed to help you prevent illness and maintain your overall health. During this visit, our healthcare professionals will:

1. Review Your Health History: We’ll discuss your medical history and any changes in your health since your last visit.
2. Health Risk Assessment: We’ll assess your current health and identify any potential risks or areas for improvement.
3. Personalized Prevention Plan: Together, we’ll create a personalized plan focusing on preventive care, screenings, and vaccinations tailored to your individual needs.
4. Medication Review: We’ll review your current medications to ensure they’re still appropriate and effective.
5. Discussion of Advance Directives: We’ll provide information and guidance on advance care planning and help you make informed decisions about your healthcare preferences.

Scheduling your Medicare Annual Wellness Visit is easy! Call our office at 1-907-357-9590 to book your appointment. Our friendly staff is ready to assist you in selecting a convenient time for your visit.

Investing in your health today can lead to a healthier tomorrow. We look forward to partnering with you on your wellness journey.

 

Medicare Annual Wellness Visit Form

Sports Physical

Complete this form if your minor child is being seen for a sports physical.

 

Sports Physical Paperwork

Well Child Questionaires

Well Child Check Questionaires: Share your childs ASQ results securely and conveniently with your childs medical provider via a confidential online portal. Ages and Stages Questionnaires (ASQs) are a key part of your childs standard well child exams from ages 2 months through 5 years. We encourage parents to complete and submit these age-appropriate developmental screening questionnaires through the secure link below prior to the child’s exam:

 

Online Screening

Medical Records

Your request will be processed in the order in which it was received. The records can be mailed, faxed, or picked up from the clinic; please mark your preference on the form.

Capstone Family Medicine
Attn: Medical Records
3122 E. Meridian Park Loop
Wasilla, AK 99654
PH: 907-357-9590
Fax: 907-357-9544
E-mail: medicalrecords@capstoneclinic.com

Release of Information

 

Copies of Medical Records

Due to the high volume and time-consuming nature of requests, Capstone Family Medicine has implemented the charges below for Medical Records.

PAPER COPIES ELECTRONIC FORMAT

1-25 pages: FREE Disc: $15.00
26-50 pages: $20.00
51-75 pages: $25.00
76-100 pages: $30.00
100+ pages: $40.00

*Charges will not exceed $40.00 and payment will be due prior to records being released.

The offices of Capstone Family Medicine will not charge a fee for processing requests for releases to medical insurance companies or for Workers’ Compensation.

If you are discharged from a Capstone Family Medicine clinic, your records may be provided to you on a one-time basis at no cost.

Alaska Department of Health and Social Services Links

Advance Health Care Directive (Living Will)

You have the right to give instructions about your own health care to the extent allowed by law. You also have the right to name someone else to make health care decisions for you to the extent allowed by law. This form allows you to do either or both of these things. It also lets you express your wishes regarding the designation of your health care provider.

Alaska Comfort One Program

Some individuals who are terminally ill do not wish to have life-saving measures, such as cardiopulmonary resuscitation (CPR), performed on them when their breathing and heartbeat stop. The Comfort One Program was established in 1996 to help health care providers identify terminally-ill people who have expressed these wishes.

WASILLA

Family Medicine
3122 E Meridian Park Loop
Wasilla, AK 99654
907-357-9590
Fax: 833-464-5213

Wasilla Clinic Hours:
Monday - Friday
8:00 am – 5:00 pm

Employee Health and
Occupational Medicine
3765 East Blue Lupine Drive
Wasilla, AK 99654
907-864-4643
Fax: 833-464-5208

PALMER

Family Medicine
12039 E Maplesprings Way, Suite A,
Palmer, AK 99645

907-745-9088
Fax: 833-464-5212

Palmer Clinic Hours:
Monday - Friday,
8:30 am – 5:00 pm

 

EAGLE RIVER

Family Medicine
17025 Snowmobile Ln
Eagle River, AK 99577
Phone: 907-694-9553
Fax: 833-464-5211

Eagle River Clinic Hours:
Monday - Friday
8:00 am – 5:00 pm

IDEAL PROTEIN

Please call our office
or e-mail Ashley
Phone: 907-357-9590
Text: 907-521-1382
Learn More

 

 

WASILLA

Family Medicine
3122 E Meridian Park Loop
Wasilla, AK 99654
907-357-9590
Fax: 833-464-5213

Wasilla Clinic Hours:
Monday - Friday
8:00 am – 5:00 pm

 

WASILLA

Employee Health and
Occupational Medicine
3765 East Blue Lupine Drive
Wasilla, AK 99654
907-864-4643
Fax: 833-464-5208

PALMER

Family Medicine
12039 E Maplesprings Way, Ste A,
Palmer, AK 99645

907-745-9088
Fax: 833-464-5212

Palmer Clinic Hours:
Monday - Friday,
8:30 am – 5:00 pm

EAGLE RIVER

Family Medicine
17025 Snowmobile Ln
Eagle River, AK 99577
Phone: 907-694-9553
Fax: 833-464-5211

Eagle River Clinic Hours:
Monday - Friday
8:00 am – 5:00 pm

Wasilla Specialty Clinics

Diabetes, Endocrinology, Dermatology, General Surgery
3066 E Meridian Park Loop,
Wasilla, AK 99654-7255

Phone: 907-357-2332
Endocrinology Fax: 833-464-5204
Dermatology Fax: 833-464-5203

Specialty Clinic Hours:
Monday - Friday
7:00 am - 5:30 pm

URGENT CARE

3765 East Blue Lupine Drive
Wasilla, AK 99654
Phone: 907-357-9560
Fax: 833-464-5215

Monday - Friday
8 am - 8 pm

Saturday & Sunday
10 am - 6 pm