Richard J. Fox, MD FACS

Foothills Medical Building
4745 Arapahoe Ave., Suite 300
Boulder, CO 80303
Phone: 303-449-3642
Fax: 303-440-7299

Patient Forms

To better serve you, please bring the following items to your visit:

Insurance Card(s) and Photo ID
Physician Referral (if you have one)
Co-pays, Co-Insurance, Unmet Deductibles that apply to your office visit
(See "Billing and Insurance" for more information)
Copy of ALL testing and records pertaining to your visit
- CD's or Films
- Reports
- Labs
- Office Notes from Referring Doctor

Completed patient forms

Prior to your initial visit, we ask that you please print and fill out the Patient Information Form. There are a total of 7 pages. Please fill out all of them to the best of your ability. If you have a medication or surgery list please attach it to your forms.

New Patient Information Forms

Please print this form SINGLE SIDED.

Download New Patient Form

HIPAA - Notice of Privacy Practice

Please read this policy prior to your visit and sign the last page of the above packet.

Download HIPAA form

Alpine Surgical Financial Policy

Please feel free to print a copy of our financial policy for your records.

Download Financial Policy form

Patient History Forms

If you are seeing us for any of the below stated problems, please fill out the corresponding form.

Download Breast History Form
Download Gallbladder History Form
Download Hemorrhoid History Form
Download Hernia History Form
Download Thyroid-Parathyroid History Form
Download Vein History Form

Pre Operation Forms

If you are seeing us for any of the below stated problems, please fill out the corresponding form.

Download Pre Operative Instructions for Vein Procedure

Post Operation Forms

Authorization Forms

If you would like to get a copy of your medical records sent to us or another office, please fill out the release form below and mail, fax or drop off at our office.

Authorization of Medical Record Release

Authorization to discuss medical and billing information with family / friends

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