New Patients
New Patients
We want to make your experience as pleasant and efficient as possible.
The best way to begin the process is to download our new patient form below.
You may fill it out and bring it with you to your first appointment.
Please contact our office if you have any questions.
NEW PATIENTS: PLEASE FILL OUT ALL THREE FORMS BELOW
The * beside a question indicates a section that must be completed in order for the form to be submitted.
You should receive 3 different email responses from us letting you know we have received each form.
Please let us know if you have any questions.
New Patient Questionnaire Part 1 - General Information
New Patient Questionnaire Part 2 - (Insurance)
New Patient Questionnaire Part 3 - Medical Records
Authorization to Release Health Information and/or Medical Records
This authorization shall be in effect until the information has been forwarded as requested - OR - until the course of treatment is complete.
PATIENT RIGHTS:
- I have the right to revoke this authorization at anytime.
- I may inspect or copy the protected health information to be disclosed as described in this document or questionnaire.
- Revocation is not effective in cases where the information has already been disclosed but will be effective going forward.
New Patient Questionnaire Part 4 - Medical History
Medical History Part 2
Please check any of the boxes that apply to family members with a history of the following medical conditions.
M - mother
F - father
S - sibling
GP - grandparent