Patient Forms

Advanced Laparoscopic, Bariatric, Endoscopic & General Surgery

The following patient forms are mailed out before your first appointment and are also available for you to download for your convenience. Each must be filled out before your first appointment OR if you have not been seen by our doctors within a year.

You may need to download Adobe Acrobat to view these files. Click here getadobereader to download the reader from  (Be sure to uncheck the box for the optional software unless you wish to install it.)

New Patient Information: This form collects all basic necessary information on our patients that we must keep on file.
Download New Patient Information PDF

Consent to Share Medical Information: This must be filled out in order for us to share their results or medical information with a family member or friend.

Download Consent To Share Medical Information PDF

Notice of Privacy Practices: This form describes how medical information about you may be used and disclosed, and how you can obtain access to this information. The privacy of your medical information is very important to us.

Download Notice of Privacy Practices PDF

Patient History: This form collects medical history information of our patients, in order for our healthcare providers to best understand our patient's medical concerns and needs.

Download Patient History Form

Financial Policy Form: Our financial policy is in place to assist you with any questions that you may have regarding your financial obligation to this practice.

Download Financial Policy Form

Alma Office

Warwick Medical Plaza
315 Warwick Drive, #3
Alma, MI 48801

Phone: (989) 463-6699
Fax: (989) 466-2574

Office Hours:
Monday - Friday
8am - 5pm

Mt. Pleasant Office

4851 E Pickard St
Mt. Pleasant, MI 48858

Phone: (989) 463-6699
Fax: (989) 466-2574

Midland Office

MidMichigan Medical Center-Midland
Towsley Building
4201 Campus Ridge Drive, Suite 4050
Midland, MI  48640
Towsley Building Entrance - take elevator on right to 4th floor

Phone: (989) 463-6699
Fax: (989) 466-2574

Office Hours:
Thursdays - Bi-Weekly
1pm - 5pm

Clare Office

602 Beach Street
Suite 2240
Clare, Michigan 48617
Across from the Dougherty Hotel, behind the hospital

Phone: (989) 463-6699
Fax: (989) 466-2574

Hospital Affiliations

All of the surgeons at Great Lakes Surgical Associates have full, unrestricted privileges to practice general surgery at the two major hospital systems in Gratiot and Isabella Counties: Gratiot Medical Center and Central Michigan Community Hospital. We perform surgery at the following locations:
    MidMichigan Medical Center - Gratiot
    Mount Pleasant Surgery Center - Mount Pleasant
    MidMichigan Medical Center - Midland
GLSA Offices are also equipped with surgery suites for indicated office procedures.

Non-Discrimination Notice - Language Assistance Services - Grievance Procedure

GLSA does not discriminate. Please read our non-discrimination policy listed below.

English - Spanish - Arabic

Individuals with Limited English Proficiency of Language Assistance Services

Affordable Care Act Grievance Procedure

S5 Box