Patient Forms
To simplify check-in, please read, download and fill out the following patient forms prior to your first visit to Rocky Mountain GYN & Hormone Center.
Reminder: Dr.Simon is highly allergic to ANGEL, SPARKS, or any other similar perfumes containing patchouli oil. Please remember not to wear perfume the day of your appointment. If you have it on when you come in, you will be asked to reschedule your appointment. Thank You!
Introduction to Dr. Simon
Patient Communications Guidelines
Notice of Privacy Practices
Medication Refill Policy
Patients - Please click on each of the forms below. Fill out, print, sign and bring EACH FORM to your appointment.
Womens Forms:
The following (6) six forms should be filled out and brought to appointment by female patients.
Payment Letters
Patient Information Form
Acknowledgment of Privacy Practices
Medical History - Women
Symptom Checklist
Current Medications Prescribed Elsewhere
Mens Forms:
The following (6) six forms should be filled out and brought to appointment by male patients.
Payment Letters
Patient Information Form
Acknowledgment of Privacy Practices
Men's Vitality
Medical History - Men
Current Medications Prescribed Elsewhere
Please be sure to bring all forms with you to your appointment. In addition, please call your insurance company provider prior to your appointment to determine your benefits and coverage. Information needed from your insurance provider: copay amount, deductible amount, amount applied toward deductible to date, and the amount insurance will cover once deductible is met (coinsurance). Thank you!
