Patient Forms & Policies
Before your appointment with us, quickly and conveniently access patient forms from Urology Specialists in Sioux Falls.
To view the forms listed below, you will need to download Adobe Reader. Please bring your completed forms with you to our office at the time of your visit.
Female Patients
Male Patients
- General Registration & Demographics
- Clinic Consent form
- Health History form
- BPH survey form (men 45+ years of age)
Additional Forms (To be filled at the request of clinic staff)
- Patient Insurance Questionnaire
- Release of Liability As To Driving of Motor Vehicle
- Request for Medical Records
- ASC Billing Notice
- ASC Notice of Rights
Download Office Policies
- Patient Financial Policy
- Patient No Show Policy
- Right to Receive a Good Faith Estimate
- Privacy Practices – HIPPA
Prescription Information
Prescription Refills:
We ask that you do not call the office with medication refill requests. Please call your pharmacy to fax us a request. Our fax number is (605) 336-7182.
Nurse Questions:
Our nursing staff is available to answer your questions and address concerns Monday through Friday from 8:00 a.m. – 4:30 p.m.
Please leave your name, a phone number, and where you can be reached with the front office staff and a nurse will return your call. All calls cannot be returned immediately, but will be responded to in a timely manner. Messages received after 4:30 pm may not be returned until the next business day.