• Call Us Today! (860) 535-4600
  • Email: care@yourcountrydoctor.com - *Please do not send medical information by email, call for appointments and Rx refills

Call Us Today! (860) 535-4600

Email! healing@yourcountrydoctor.com

Patient Forms

Adult Health Assessment

Dr. Pecher
Adult Health 
Assessment Form

Authorization to Disclose PHI

Dr. Pecher
Authorization To 
Disclose PHI

HIPAA Acknowledgement

Dr. Pecher
HIPAA 
Acknowledgement

HIPAA Form

Dr. Pecher
HIPAA 
Form

Medication List

Dr. Pecher
Medication 
List

Patient Registration

Dr. Pecher Patient
Registration Form

Release of Information

Form

Dr. Pecher
Release of Information

Text/Email Consent

Dr. Pecher
 Text/Email Consent