Forms

Patient Forms

For your convenience, Evergreen Adult Medicine (Evergreen Medicine) has consolidated all patient forms on a single page. Independently owned for 20 years, our clinic provides compassionate care at affordable rates.

Forms requested outside of an appointment incur a fee. To qualify, the patient must have been seen by an Evergreen Medicine provider within the past six months for the condition related to the form. FMLA forms require a scheduled appointment and are not included in the standard form fee.

If you have any questions about these forms or anything else related to healthcare services we offer, please call today.

New Patient Form

Please complete the new patient form to request an appointment. We'll get in touch with you within one or two business days with appointment instructions.

Weight Management Program

To sign up for professional assistance with weight loss, please fill out and submit our weight management program form.

Controlled Substance Agreement

Certain medications prescribed by Evergreen Medicine are controlled due to their potential risks. Patients must complete a Controlled Substance Agreement annually to confirm their understanding of these risks and their responsibilities in safely managing the medication. Completion of this form ensures acknowledgment of both office policies and the patient’s personal obligations for proper use and stewardship of controlled substances.

For up-to-date compliance, please complete in full our controlled substance agreement form in order to receive controlled medications from Evergreen Medicine. Lack of consent without completed form may delay prescription requests.

Medical Marijuana

Evergreen Medical has a dedicated website for making appointments for medical marijuana certification. Schedule an appointment with one of our providers now.

Learn more about registering with Pennsylvania for medical marijuana certification.

Learn more about registering with Maryland for medical marijuana certification.

Opioid/Alcohol Abuse Treatment

Are you struggling with opioid or alcohol abuse and want to break the cycle? Evergreen Medical offers a treatment and recovery program to help you get clean and stay clean. Submit the online form to get started and we'll schedule an appointment for you.

Adult ADHD Questionnaire

Do you have trouble concentrating or finishing tasks? Is it affecting your work or personal life? Take this survey.