Printable Forms
Filling out these forms prior to your initial visit will help your provider in providing the best possible healthcare.
(If you have questions or if you need assistance filling out forms, please contact our office at (530) 798-5003.)
Incoming Medical Records Release
Outgoing Medical Records Release
New Patient Personal Health Information
MDVIP Patient Agreement
This Patient Agreement specifies the terms and conditions under which you, the undersigned patient, may participate in the program offered by Dr. Loesch.
Annual Wellness Exam Questionaire and Plan
People who are successful at making lifestyle changes take time to write out specific goals and a plan of action. Review the various area of your health. Decide in which areas you would like to make improvement.
Annual Wellness Lab Instructions
Please click this link for Instructions, Lab location and hours. *Your Annual Wellness Labs can ONLY be drawn at Quest. Please remember to have your labs drawn one week prior to your scheduled appointment time. Patients are required to pick up their lab requisition slip prior to having labs drawn, unless other arrangements with office have been made.
Chronic Pain Chart
For all refills on controlled medications, please fill out the Chronic Pain Chart and return to our office via fax, e-mail or by hand. Prescription refills will be ready in 48 hours for pick-up. (For more information on prescription refills, please see Patient Policies).
POLST
Physicians Orders for Life-Sustaining Treatment (POLST)
Advanced Care Planning
There's only one person who is truly qualified to tell health care providers how you feel about different kinds of health care issues----and that's you. You can help assure your wishes will direct future health care decisions through the process of advance care planning. The information below is from the California Coalition of Compassionate Care Organization.