Returning Patient Forms

Securely complete your patient registration forms for Back In Action Medical Center.

To be used for provider communication, follow up, patient portal, and practice related material. We DO NOT share email information with other parties. You may choose to remove any time

Insurance Information

In Case of Emergency

Reason for Today's Visit

Medical History

Family History

Social History

Review of Systems

(Check all that apply)

Medical Information Release Form

HIPPA Release Form

This release of information will remain in effect until terminated by me in writing.

Release of Information



When an appointment is scheduled for you with Michael Carpino or Misty Gaddis at Back in Action/Best Life Primary Care, it is your responsibility to confirm your appointment 24hrs prior to the appointment time. The front desk team will call and or email you to confirm your appointment. In the event you do not answer a voice mail will be left. If you as the patient do not make conformation of your scheduled appointment within 24hrs your appointment will be canceled and rescheduled for a later date. If you have an appointment scheduled and you do not show up, you will be billed a $50.00 no show fee. We understand that circumstances will arise that will result in you having to cancel please give us a courtesy call 24hrs prior to your scheduled time to prevent the no show fee being charged.

We value you as one of our patients and hope you understand why this is a necessary office policy.

Please sign and date below stating your acknowledgement of this policy.