CMC's Patient Forms

Here you will find the Clermont Medical Center's downloadable PDF forms. Click on any of the links below to open the form in a new window. These forms can be easily printed and filled out prior to your visit.

If you feel you need to go to the ER for non-life-threatening issues, please contact the office first.
During Office Hours:  (352) 394-4035
After Office Hours: Leesburg Communications at (352) 728-7586.

 
Clermont Medical Center Personal Information Form
Click Here to Download - 1 Page
 
Clermont Medical Center Medical History Form
Click Here to Download - 5 Pages
 
Clermont Medical Center Authorization to Disclose Protected Health Information
Click Here to Download - 2 Pages
 
Clermont Medical Center Consent to Use or Disclose Information for Treatment Payment or Health Care Operations
Click Here to Download - 2 Pages
 
Clermont Medical Center Notice of Privacy Practices and Policies
Click Here to Download - 6 Pages