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Family Practice Associates
1304 Military Rd
Benton, AR 72015
501-778-0934 
Serving Saline County since 1980
Patient Forms
Please print and fill out all necessary forms before your scheduled appointment. This will help to decrease your wait time, as well as allow you ample time to complete all insurance and previous health information. To download forms, you will need to have Adobe Reader installed. Click on the icon to the left of each description to download the form. 

All new patients, please print and fill out all adult or child forms marked with the ** and bring with you to your appointment.
**Patient Registration form  
(also should be filled out by all patients who haven't been to our clinic in the past year, or patients that need to update their name, insurance, address, or other information) 


​**History and Physical form -- adults


**Privacy Authorization form  
(should you need to change who can access your medical information, please print and bring this form)







​**Minor Patient Registration form  



​**History and Physical form -- children



​**Privacy Authorization form  
(should you need to change who can access your child's medical information, please print and bring this form)


**Minor Patient Consent for Treatment form
(Effective 5/1/16, all minor patients must have this form signed by a parent/legal guardian to come to an appointment alone or for someone other than a parent to authorize treatment.)



School Physical Form
(This form must be filled out and signed by a parent prior to school physical appointments!)
Adult New Patient Forms
Notice of Privacy Practices



Medical Records Release Form
Child New Patient Forms 
(anyone under age 18)