Patient Forms

For your convenience, Evergreen Adult Medicine (Evergreen Medicine) has grouped our patient forms here on one page. Iindependently owned for 20 years, our clinic offers low fee rates and provides compassionate health care.

In case you have other forms that must be completed at times when you do not have an appointment, we charge a fee for this service. The patient must have been seen by an Evergreen Medicine provider within the past six months regarding this condition. All FMLA forms must be accompanied by an appointment and are not covered by the 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 controlled medications prescribed by Evergreen Medicine's providers are protected due to the potential dangers associated with them. We require our patients to sign a controlled substance agreement form each year to confirm their understanding of the potential risks as well as patient responsibilities accompanying these medications. As an informed patient, you're required to acknowledge our office policies as well as your own patient responsibility with the stewardship of any controlled substance prescription.

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.