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

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:

 

Palmer Online Screening
Wasilla Online Screening     Eagle River 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.

ANCHORAGE

Family Medicine
1100 E Dimond Blvd,
Anchorage AK 99515
Phone: 907-333-2133
Fax: 907-333-2139

PRUDHOE BAY

Employee Health and
Occupational Medicine
501 1st Street
Prudhoe Bay, AK 99734

EAGLE RIVER

Family Medicine
17025 Snowmobile Ln
Eagle River, AK 99577
Phone: 907-694-9553
Fax: 907-694-9585

PALMER

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

907-745-9088
Fax: 907-745-9099

Palmer Clinic Hours:
Monday - Friday,
9:00 am – 5:00 pm

 

WASILLA

Family Medicine
3122 E Meridian Park Loop
Wasilla, AK 99654
907-357-9590
Fax: 907-357-9593

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

KENAI

Family Medicine
10543 Kenai Spur Hwy
Kenai, AK 99611
Phone: (907) 395-0463
Fax: (907) 395-0483

Kenai 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

URGENT CARE

3765 East Blue Lupine Drive
Wasilla, AK 99654
Phone: 907-357-9560
Fax: 907-357-9596

Wasilla Employee Health and Urgent Care will be relocating to 3765 East Blue Lupine Drive on September 12th.

WASILLA

Family Medicine
3122 E Meridian Park Loop
Wasilla, AK 99654
907-357-9590
Fax: 907-357-9593

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

PALMER

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

907-745-9088
Fax: 907-745-9099

Palmer Clinic Hours:
Monday - Friday,
9:00 am – 5:00 pm

PRUDHOE BAY

Employee Health and
Occupational Medicine
501 1st Street
Prudhoe Bay, AK 99734

ANCHORAGE

Family Medicine
1100 E Dimond Blvd,
Anchorage AK 99515
Phone: 907-333-2133
Fax: 907-333-2139

 

EAGLE RIVER

Family Medicine
17025 Snowmobile Ln
Eagle River, AK 99577
Phone: 907-694-9553
Fax: 907-694-9585

KENAI

Family Medicine
10543 Kenai Spur Hwy
Kenai, AK 99611
Phone: (907) 395-0463
Fax: (907) 395-0483

Kenai 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

URGENT CARE

3765 East Blue Lupine Drive
Wasilla, AK 99654
Phone: 907-357-9560
Fax: 907-357-9596

Wasilla Employee Health and Urgent Care will relocate to 3765 East Blue Lupine Drive on September 12th.