{"id":1226,"date":"2020-02-10T16:45:51","date_gmt":"2020-02-10T16:45:51","guid":{"rendered":"https:\/\/www.toplinemd.com\/epe-llc\/?page_id=1226"},"modified":"2026-04-09T14:35:16","modified_gmt":"2026-04-09T18:35:16","slug":"forms","status":"publish","type":"page","link":"https:\/\/www.toplinemd.com\/epe\/forms\/","title":{"rendered":"Forms"},"content":{"rendered":"<p><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1 nonhundred-percent-fullwidth non-hundred-percent-height-scrolling fusion-equal-height-columns fullwidth-padding-box\" style=\"--awb-background-position:left top;--awb-border-sizes-top:0px;--awb-border-sizes-bottom:0px;--awb-border-sizes-left:0px;--awb-border-sizes-right:0px;--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;--awb-padding-top:110px;--awb-padding-bottom:90px;--awb-margin-bottom:0px;--awb-background-color:#f5f5f5;--awb-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-0 fusion_builder_column_1_1 1_1 fusion-one-full fusion-column-first fusion-column-last fusion-column-no-min-height\" style=\"--awb-bg-size:cover;--awb-margin-bottom:0px;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-column-wrapper-legacy\"><div class=\"fusion-sep-clear\"><\/div><div class=\"fusion-separator fusion-full-width-sep\" style=\"margin-left: auto;margin-right: auto;width:100%;\"><div class=\"fusion-separator-border sep-single sep-solid\" style=\"--awb-height:20px;--awb-amount:20px;--awb-sep-color:#520e54;border-color:#520E54;border-top-width:5px;\"><\/div><\/div><div class=\"fusion-sep-clear\"><\/div><div class=\"fusion-clearfix\"><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-1 fusion_builder_column_1_1 1_1 fusion-one-full fusion-column-first fusion-column-last fusion-column-no-min-height\" style=\"--awb-padding-top:45px;--awb-padding-right:45px;--awb-padding-bottom:45px;--awb-padding-left:15px;--awb-bg-color:#ffffff;--awb-bg-color-hover:#ffffff;--awb-bg-size:cover;--awb-margin-bottom:0px;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-column-wrapper-legacy\"><div class=\"fusion-column-content-centered\"><div class=\"fusion-column-content\"><div class=\"fusion-text fusion-text-1\"><h2 style=\"text-align: center;\">All Forms<\/h2>\n<\/div><\/div><\/div><div class=\"fusion-clearfix\"><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-2 fusion_builder_column_1_2 1_2 fusion-one-half fusion-column-first\" style=\"--awb-padding-top:20px;--awb-padding-right:20px;--awb-padding-bottom:20px;--awb-padding-left:20px;--awb-bg-color:#ffffff;--awb-bg-color-hover:#ffffff;--awb-bg-size:cover;width:50%;width:calc(50% - ( ( 0 ) * 0.5 ) );margin-right: 0px;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-column-wrapper-legacy\"><ul style=\"--awb-size:18px;--awb-iconcolor:#520e54;--awb-line-height:30.6px;--awb-icon-width:30.6px;--awb-icon-height:30.6px;--awb-icon-margin:12.6px;--awb-content-margin:43.2px;\" class=\"fusion-checklist fusion-checklist-1 fusion-checklist-default type-icons\"><li class=\"fusion-li-item\" style=\"\"><span class=\"icon-wrapper circle-no\"><i class=\"fusion-li-icon fa-angle-right fas\" aria-hidden=\"true\"><\/i><\/span><div class=\"fusion-li-item-content\">\n<p><a href=\"\/wp-content\/uploads\/sites\/11\/2020\/01\/1-OFFICE-POLICY-PTS.pdf\" target=\"_blank\" rel=\"noopener noreferrer\">Office Policy<\/a><\/p>\n<\/div><\/li><li class=\"fusion-li-item\" style=\"\"><span class=\"icon-wrapper circle-no\"><i class=\"fusion-li-icon fa-angle-right fas\" aria-hidden=\"true\"><\/i><\/span><div class=\"fusion-li-item-content\">\n<p><a href=\"\/wp-content\/uploads\/sites\/11\/2020\/01\/2-NEW-PT-INFO-English.pdf\" target=\"_blank\" rel=\"noopener noreferrer\">Patient Information Form English<\/a><\/p>\n<\/div><\/li><li class=\"fusion-li-item\" style=\"\"><span class=\"icon-wrapper circle-no\"><i class=\"fusion-li-icon fa-angle-right fas\" aria-hidden=\"true\"><\/i><\/span><div class=\"fusion-li-item-content\">\n<p><a href=\"\/wp-content\/uploads\/sites\/11\/2020\/01\/3-Notice-of-Privacy-Acknowledgement-.pdf\" target=\"_blank\" rel=\"noopener noreferrer\">Notice of Privacy Acknowledgement<\/a><\/p>\n<\/div><\/li><li class=\"fusion-li-item\" style=\"\"><span class=\"icon-wrapper circle-no\"><i class=\"fusion-li-icon fa-angle-right fas\" aria-hidden=\"true\"><\/i><\/span><div class=\"fusion-li-item-content\"><a href=\"\/wp-content\/uploads\/sites\/11\/2020\/01\/4-PT-notice-malpractice.pdf\" target=\"_blank\" rel=\"noopener noreferrer\">Patient Notice Malpractice English and Spanish<\/a><\/div><\/li><li class=\"fusion-li-item\" style=\"\"><span class=\"icon-wrapper circle-no\"><i class=\"fusion-li-icon fa-angle-right fas\" aria-hidden=\"true\"><\/i><\/span><div class=\"fusion-li-item-content\">\n<p><a href=\"\/wp-content\/uploads\/sites\/11\/2020\/01\/5-Email-Consent-Form-English.pdf\" target=\"_blank\" rel=\"noopener noreferrer\">Email Consent Form English<\/a><\/p>\n<\/div><\/li><li class=\"fusion-li-item\" style=\"\"><span class=\"icon-wrapper circle-no\"><i class=\"fusion-li-icon fa-angle-right fas\" aria-hidden=\"true\"><\/i><\/span><div class=\"fusion-li-item-content\">\n<p><a href=\"\/wp-content\/uploads\/sites\/11\/2020\/01\/PT-Bill-of-Rights-English-Spanish-Copy.pdf\" target=\"_blank\" rel=\"noopener noreferrer\">Bill of Rights English and Spanish<\/a><\/p>\n<\/div><\/li><\/ul><div class=\"fusion-clearfix\"><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-3 fusion_builder_column_1_2 1_2 fusion-one-half fusion-column-last\" style=\"--awb-padding-top:20px;--awb-padding-right:20px;--awb-padding-bottom:20px;--awb-padding-left:20px;--awb-bg-color:#ffffff;--awb-bg-color-hover:#ffffff;--awb-bg-size:cover;width:50%;width:calc(50% - ( ( 0 ) * 0.5 ) );\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-column-wrapper-legacy\"><ul style=\"--awb-size:18px;--awb-iconcolor:#520e54;--awb-line-height:30.6px;--awb-icon-width:30.6px;--awb-icon-height:30.6px;--awb-icon-margin:12.6px;--awb-content-margin:43.2px;\" class=\"fusion-checklist fusion-checklist-2 fusion-checklist-default type-icons\"><li class=\"fusion-li-item\" style=\"\"><span class=\"icon-wrapper circle-no\"><i class=\"fusion-li-icon fa-angle-right fas\" aria-hidden=\"true\"><\/i><\/span><div class=\"fusion-li-item-content\">\n<p><a href=\"\/wp-content\/uploads\/sites\/11\/2020\/01\/1-OFFICE-POLICY-PTS-SPANISH.pdf\" target=\"_blank\" rel=\"noopener noreferrer\">Office Policy Spanish<\/a><\/p>\n<\/div><\/li><li class=\"fusion-li-item\" style=\"\"><span class=\"icon-wrapper circle-no\"><i class=\"fusion-li-icon fa-angle-right fas\" aria-hidden=\"true\"><\/i><\/span><div class=\"fusion-li-item-content\">\n<p><a href=\"\/wp-content\/uploads\/sites\/11\/2020\/01\/2-NEW-PATIENT-INFO-Spanish.pdf\" target=\"_blank\" rel=\"noopener noreferrer\">Patient Info Spanish<\/a><\/p>\n<\/div><\/li><li class=\"fusion-li-item\" style=\"\"><span class=\"icon-wrapper circle-no\"><i class=\"fusion-li-icon fa-angle-right fas\" aria-hidden=\"true\"><\/i><\/span><div class=\"fusion-li-item-content\">\n<p><a href=\"\/wp-content\/uploads\/sites\/11\/2020\/01\/3-Aviso-De-Privacidad-Reconocimiento.pdf\" target=\"_blank\" rel=\"noopener noreferrer\">Aviso De Privacidad Reconocimiento<\/a><\/p>\n<\/div><\/li><li class=\"fusion-li-item\" style=\"\"><span class=\"icon-wrapper circle-no\"><i class=\"fusion-li-icon fa-angle-right fas\" aria-hidden=\"true\"><\/i><\/span><div class=\"fusion-li-item-content\">\n<p><a href=\"\/wp-content\/uploads\/sites\/11\/2020\/01\/5-Email-Consent-Form-Spanish.pdf\" target=\"_blank\" rel=\"noopener noreferrer\">Email Consent Form (Spanish)<\/a><\/p>\n<\/div><\/li><li class=\"fusion-li-item\" style=\"\"><span class=\"icon-wrapper circle-no\"><i class=\"fusion-li-icon fa-angle-right fas\" aria-hidden=\"true\"><\/i><\/span><div class=\"fusion-li-item-content\">\n<p><a href=\"\/wp-content\/uploads\/sites\/11\/2020\/01\/PT-Bill-of-Rights-English-Spanish-.pdf\" target=\"_blank\" rel=\"noopener noreferrer\">Bill of Rights English &#038; Spanish<\/a><\/p>\n<\/div><\/li><\/ul><div class=\"fusion-clearfix\"><\/div><\/div><\/div><\/div><\/div><div class=\"fusion-bg-parallax\" data-bg-align=\"center center\" data-direction=\"up\" data-mute=\"false\" data-opacity=\"100\" data-velocity=\"-0.3\" data-mobile-enabled=\"false\" data-break_parents=\"0\" data-bg-image=\"https:\/\/www.toplinemd.com\/epe\/wp-content\/uploads\/sites\/11\/2020\/02\/Hp-request-an-appointment-1.jpg\" data-bg-repeat=\"false\" data-bg-gradient-type=\"linear\" data-bg-gradient-angle=\"180\" data-bg-gradient-start-color=\"rgba(0,0,0,0.2)\" data-bg-gradient-start-position=\"0\" data-bg-gradient-end-color=\"rgba(0,0,0,0.2)\" data-bg-gradient-end-position=\"100\" data-bg-radial-direction=\"center center\" ><\/div><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-2 fusion-parallax-up nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"--awb-border-sizes-top:0px;--awb-border-sizes-bottom:0px;--awb-border-sizes-left:0px;--awb-border-sizes-right:0px;--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;--awb-padding-top:100px;--awb-padding-bottom:100px;--awb-background-image:linear-gradient(180deg, rgba(0,0,0,0.2) 0%,rgba(0,0,0,0.2) 100%),url(https:\/\/www.toplinemd.com\/epe\/wp-content\/uploads\/sites\/11\/2020\/02\/Hp-request-an-appointment-1.jpg);;--awb-background-size:cover;--awb-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-4 fusion_builder_column_1_1 1_1 fusion-one-full fusion-column-first fusion-column-last fusion-column-no-min-height\" style=\"--awb-bg-blend:overlay;--awb-bg-size:cover;--awb-margin-bottom:0px;\"><div class=\"fusion-column-wrapper fusion-flex-column-wrapper-legacy\"><div class=\"fusion-text fusion-text-2 fusion-text-no-margin\" style=\"--awb-margin-bottom:20px;\"><h2 class=\"entrust-health-title\">Entrust Your Health<br \/>\nTo Our Doctors<\/h2>\n<\/div><div class=\"fusion-button-wrapper fusion-aligncenter\"><a class=\"fusion-button button-flat button-large button-default fusion-button-default button-1 fusion-button-default-span \" style=\"--button_text_transform:uppercase;\" target=\"_self\" href=\"\/epe\/contact-us\/\"><span class=\"fusion-button-text awb-button__text awb-button__text--default\">Request an Appointment<\/span><\/a><\/div><div class=\"fusion-clearfix\"><\/div><\/div><\/div><\/div><\/div>\n<div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-3 hundred-percent-fullwidth non-hundred-percent-height-scrolling fusion-equal-height-columns logos-footer\" style=\"--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;--awb-padding-top:10px;--awb-padding-bottom:0px;--awb-padding-left:60px;--awb-background-color:#f0f3f6;--awb-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-5 fusion_builder_column_1_2 1_2 fusion-one-half fusion-column-first logo-footer\" style=\"--awb-padding-top:40px;--awb-bg-size:cover;width:50%;width:calc(50% - ( ( 0 ) * 0.5 ) );margin-right: 0px;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-column-wrapper-legacy\"><div class=\"fusion-image-element in-legacy-container\" style=\"--awb-caption-title-font-family:var(--h2_typography-font-family);--awb-caption-title-font-weight:var(--h2_typography-font-weight);--awb-caption-title-font-style:var(--h2_typography-font-style);--awb-caption-title-size:var(--h2_typography-font-size);--awb-caption-title-transform:var(--h2_typography-text-transform);--awb-caption-title-line-height:var(--h2_typography-line-height);--awb-caption-title-letter-spacing:var(--h2_typography-letter-spacing);\"><span class=\" fusion-imageframe imageframe-none imageframe-1 hover-type-none\"><a class=\"fusion-no-lightbox\" href=\"\/epe\/\" target=\"_self\" aria-label=\"EPE-LLC\"><img decoding=\"async\" width=\"270\" height=\"100\" src=\"https:\/\/www.toplinemd.com\/epe\/wp-content\/uploads\/sites\/11\/2020\/12\/EPE-LLC.png\" alt class=\"img-responsive wp-image-1282\" srcset=\"https:\/\/www.toplinemd.com\/epe\/wp-content\/uploads\/sites\/11\/2020\/12\/EPE-LLC-200x74.png 200w, https:\/\/www.toplinemd.com\/epe\/wp-content\/uploads\/sites\/11\/2020\/12\/EPE-LLC.png 270w\" sizes=\"(max-width: 850px) 100vw, 270px\" \/><\/a><\/span><\/div><div class=\"fusion-clearfix\"><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-6 fusion_builder_column_1_2 1_2 fusion-one-half fusion-column-last logo-footer\" style=\"--awb-padding-top:40px;--awb-bg-size:cover;width:50%;width:calc(50% - ( ( 0 ) * 0.5 ) );\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-column-wrapper-legacy\"><div class=\"fusion-image-element in-legacy-container\" style=\"--awb-max-width:270px;--awb-caption-title-font-family:var(--h2_typography-font-family);--awb-caption-title-font-weight:var(--h2_typography-font-weight);--awb-caption-title-font-style:var(--h2_typography-font-style);--awb-caption-title-size:var(--h2_typography-font-size);--awb-caption-title-transform:var(--h2_typography-text-transform);--awb-caption-title-line-height:var(--h2_typography-line-height);--awb-caption-title-letter-spacing:var(--h2_typography-letter-spacing);\"><span class=\" fusion-imageframe imageframe-none imageframe-2 hover-type-none\"><a class=\"fusion-no-lightbox\" href=\"https:\/\/www.toplinemd.com\" target=\"_blank\" aria-label=\"TopLine MD-RegisterR_Stacked_Logo_rgb_color\" rel=\"noopener noreferrer\"><img decoding=\"async\" width=\"1576\" height=\"376\" src=\"https:\/\/www.toplinemd.com\/epe\/wp-content\/uploads\/sites\/11\/2026\/03\/TopLine-MD-RegisterR_Stacked_Logo_rgb_color.png\" alt class=\"img-responsive wp-image-1368\" srcset=\"https:\/\/www.toplinemd.com\/epe\/wp-content\/uploads\/sites\/11\/2026\/03\/TopLine-MD-RegisterR_Stacked_Logo_rgb_color-200x48.png 200w, https:\/\/www.toplinemd.com\/epe\/wp-content\/uploads\/sites\/11\/2026\/03\/TopLine-MD-RegisterR_Stacked_Logo_rgb_color-400x95.png 400w, https:\/\/www.toplinemd.com\/epe\/wp-content\/uploads\/sites\/11\/2026\/03\/TopLine-MD-RegisterR_Stacked_Logo_rgb_color-600x143.png 600w, https:\/\/www.toplinemd.com\/epe\/wp-content\/uploads\/sites\/11\/2026\/03\/TopLine-MD-RegisterR_Stacked_Logo_rgb_color-800x191.png 800w, https:\/\/www.toplinemd.com\/epe\/wp-content\/uploads\/sites\/11\/2026\/03\/TopLine-MD-RegisterR_Stacked_Logo_rgb_color-1200x286.png 1200w, https:\/\/www.toplinemd.com\/epe\/wp-content\/uploads\/sites\/11\/2026\/03\/TopLine-MD-RegisterR_Stacked_Logo_rgb_color.png 1576w\" sizes=\"(max-width: 850px) 100vw, 600px\" \/><\/a><\/span><\/div><div class=\"fusion-clearfix\"><\/div><\/div><\/div><\/div><\/div>\n<\/p>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":3,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"open","ping_status":"open","template":"100-width.php","meta":{"footnotes":"","_links_to":"","_links_to_target":""},"class_list":["post-1226","page","type-page","status-publish","hentry"],"aioseo_notices":[],"aioseo_head":"\n\t\t<!-- All in One SEO 4.9.10 - aioseo.com -->\n\t<meta name=\"description\" content=\"All Forms Office Policy Patient Information Form English Notice of Privacy Acknowledgement Patient Notice Malpractice English and Spanish Email Consent Form\" \/>\n\t<meta name=\"robots\" content=\"max-image-preview:large\" \/>\n\t<link rel=\"canonical\" href=\"https:\/\/www.toplinemd.com\/epe\/forms\/\" \/>\n\t<meta name=\"generator\" content=\"All in One SEO (AIOSEO) 4.9.10\" \/>\n\n\t\t<!-- Global site tag (gtag.js) - Google Analytics -->\n<script async 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