MyCatholicDoctor - Intake Forms

Thank you for choosing MyCatholicDoctor. This page contains downloadable intake forms that help our clinicians prepare for their visit with you. The forms on this page supplement the standard intake forms that may be sent to your email.

To get started, please select your appointment type below to find any intake forms required for your visit. The sooner you complete and submit your forms, the more time your provider will have to review your information and understand your health concerns before your visit. The end of this page contains detailed instructions on how to securely send your completed forms back to your clinician.

New Patients

If you are a new patient, you will be receiving a Tebra Patient Portal activation email in the coming days. This email will have instructions for activating your Tebra Patient Portal account.

You will also have additional intake forms sent to your email. You must first activate your Tebra Patient Portal account before you can fill out these intake forms.

“cure the sick who are there, and say to them, ‘The kingdom of God has come near to you.’” – Luke 10:9

Appointment Types:

Functional Medicine

Integrative Health Questionnaire – Required for NEW functional medicine patients before their initial visit.
Medical Symptoms Questionnaire – Required for EVERY functional medicine visit.

Mental Health

Please just work on completing the Tebra intake forms that you will receive in the coming days before your visit. Rest assured that you do not need to complete ANY intake forms on this webpage. Tebra intake forms are filled out only once a year. If you already completed Tebra intake forms in the past year for this clinician (or another MyCatholicDoctor clinician) but then you moved or your information has changed, please send us an email.

Natural Family Planning (NFP)

Physical Therapy (PT)

PT with Dr. Sheri Donaldson:

Balance Concepts PC – Required ONLY for first visit.
Dizziness Handicap Inventory – Required ONLY for first visit.

All Other PT Patients:
Please just work on completing the Tebra intake forms that you will receive in the coming days before your visit. Rest assured that you do not need to complete ANY intake forms on this webpage. Tebra intake forms are filled out only once a year. If you already completed Tebra intake forms in the past year for this clinician (or another MyCatholicDoctor clinician) but then you moved or your information has changed, please send us an email.

Urgent Care

Virtual Dermatology

Virtual Primary Care / Pediatrics

Pediatrics with Dr. Rebecca Sweeney:

Food insecurity – Required ONLY for first pediatric visit.
Pediatric Symptom Checklist (Parent) – Required ONLY for first pediatric visit.
Pediatric Symptom Checklist (Patient-Youth) – Required ONLY for first pediatric visit.

All Others:
Please just work on completing the Tebra intake forms that you will receive in the coming days before your visit. Rest assured that you do not need to complete ANY intake forms on this webpage. Tebra intake forms are filled out only once a year. If you already completed Tebra intake forms in the past year for this clinician (or another MyCatholicDoctor clinician) but then you moved or your information has changed, please send us an email.

Women's Fertility Care & Gynecology

General Use

Only use the form below if your clinician specifically requests this form to be completed.

Core / General Use Intake Form

Abortion Pill Reversal

Care for the Aging

Caregiver Consultations with Aimee Gustitis

Cognitive Impairment & Dementia Services

COVID Care

Creighton High School & College Program

Dr. Bazger - Life Flows MEDICINE & SURGERY PLLC

Patient Health History Questionnaire – Required ONLY for first visit.
Primary Local Physician & Pharmacy Information – Required for EVERY visit.
Informed Consent and Letter of Understanding – Required for EVERY visit.

Endocrinology

Fertility with Dr. Craig

Genetic Counseling

Lactation Services

Lifestyle Medicine

Medical Weight Management

Rules for use of anti-obesity medications – Required for NEW weight management patients having their initial visit.
Consent Form – Required for NEW weight management patients having their initial visit.

Podiatry

Rheumatology

Speech Therapy

Support Group Sessions with Matt Estrade

Travel Medicine

Vaccine & Medication Consultation

Wellness Services

Can't Find Your Appointment Type?

More Appointment Types

How To Send Us Your Completed Intake Forms:

All intake forms on this page are downloadable PDFs.

1) Download
Download the form(s) to your computer before filling them out. Please note, your web browser may open the PDFs in your browser. If this happens please use the PDF viewer’s download button to download the PDF file to your computer.

2) Fill out the form(s)
Find the downloaded form(s) on your computer and fill them out.

3) Save your work
Before sending your forms back to us please make sure to save your form(s) so your answers will not be lost.

4) Log in to the Tebra Patient Portal
You will be sending your completed form(s) to us in a secure method using our Patient Portal. New patients: please see the note below regarding your Patient Portal activation.

5) Send your completed form(s)
Please go to the messages section of the Tebra Patient Portal and send your clinician a message with your completed form(s) attached. Click here to download detailed instructions for sending your intake forms using our Patient Portal

New Patients: if you are a new patient you will be receiving your Tebra Patient Portal activation email in the coming days. If you do not receive this activation email, please check your spam folder or send us an email.

Tebra Patient Portal

New Patients

If you are a new patient, you will be receiving a Tebra Patient Portal activation email in the coming days. This email will have instructions for activating your Tebra Patient Portal account.

You will also have additional intake forms sent to your email. You must first activate your Tebra Patient Portal account before you can fill out these intake forms.

Intake Form Tips

All intake forms on this page are downloadable PDFs.
Download the form(s) to your computer before filling them out.
Read the detailed instructions for how to send us your completed forms.

Medical Records

The forms below are used to request having medical records sent to or from MyCatholicDoctor. Your written authorization is required prior to any records being transferred.

Authorization to release records TO MyCatholicDoctor

Authorization to release records FROM MyCatholicDoctor

Need Help?

Do you need help submitting your intake forms? Please send us an email or call us and leave a message. We’ll do our best to help you get your forms sent in as soon as possible.