Patient Intake Forms

Below are the forms which you can print out at home and bring to our clinic to save time.

Patient Intake Form :This form is for patients who are new to the clinic. Basic health information, areas of complaint, medication information, etc. will be submitted via these forms.

Insurance and Payment Policy Signature Form :This form covers payment and account balance policies and our current policy regarding insurance coverage. We do not currently accept insurance but we can provide you with proof of payment which can be submitted to your insurance company. This signature form will be updated annually.

Children's Intake Form :This form is for minor patients who are new to the clinic. Basic health information, areas of complaint, medication information, etc. will be submitted via these forms. Custodial consent is required.

HIPPA Notice of Privacy :This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment or health care operations (TPO) and for other purposes that are permitted or required by law.

Cancelation document: We do our best to accomodate patient. We appreciate your cooperation with our cancellation policy as well as having respect for those who have scheduled appointments.