Dr.  Don Selvey
  • Home Page
  • Pain Relief - Not Drugs
  • Hormone Evaluation
  • Cosmetic Therapy
  • Weight Loss
  • Peptide Therapy
  • Primary Care
  • Doc Talks
  • About Us
  • Forms
Dr.  Don Selvey
  • Home Page
  • Pain Relief - Not Drugs
  • Hormone Evaluation
  • Cosmetic Therapy
  • Weight Loss
  • Peptide Therapy
  • Primary Care
  • Doc Talks
  • About Us
  • Forms

Forms For Your Convenience

Forms for most new patients

New Patient Information (docx)Download
New Patient Consent for Treatment (docx)Download
Past Medical History (docx)Download
Release of Medical Records (docx)Download
HIPAA Policy Acknowledgment (docx)Download
Our HIPAA Policy and Notice (docx)Download

Forms for all Medical Marijuana Patients

You may print and complete these forms prior to your appointment and email to info@coppervalleymedical.com or bring them to your appointment.

Patient Attestation Form - Required by ADHS (pdf)Download
Patient Information - MMJ (docx)Download
HIPAA (docx)Download
Consent for Limited Treatment (docx)Download
Limited Past Medical History (docx)Download
MMJ Advisory (docx)Download
Reproductive Warning (docx)Download
Release of Medical Records (docx)Download
  • Home Page
  • Hormone Evaluation
  • Cosmetic Therapy
  • Peptide Therapy
  • Primary Care
  • About Us
  • Forms

Don Selvey, NMD, PLLC

4955 S. Alma School Road, Ste 10, Chandler, AZ 85248 US

(602) 566-2015 (602) 680-1025 fax

Copyright © 2020 Copper Valley Medical, LLC - All Rights Reserved.

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