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Patient Forms

To expedite your visit, please download and complete your registration forms in advance.

         1. You may EMAIL your completed forms prior to your appointment to:     

                                                     [email protected]  

         2. You may also bring your forms with you on the day of your appointment (this option may add to your total visit time).

         3. You may also complete forms at our Center (please arrive an additional 30 minutes prior to your appointment).

 

Form instructions (please read the following to determine which forms apply to you):

• All patients: Complete the “Patient Registration Form;” “Medical History Form;” “General Disclaimer Form,” and the “Release of Information Authorization Form.”
• Medicare patients: Complete the “Medicare (and Medi-gap) Acknowledgment Form” (in addition to the first 4 forms).
• Patients with two or more insurance plans: Complete the “Additional Insurance Form” (in addition to the first 4 forms).
• Minors (age 17 and under): All patients under the age of 18 must be accompanied by a parent (or another legal guardian) for their initial consultation. Following the initial consultation, a minor patient can be seen and treated without a parent (or another legal guardian) present only if the “Minor Patient Consent Form” is completed. In addition to completing this form, please see our staff for additional details.

Forms:

• Patient Registration Form
• Medical History Form
• General Disclaimer Form
• Release of Information Authorization Form
• Medicare – Medi-gap Acknowledgement Form (complete this form if you are a Medicare patient)
• Additional Insurance Form (complete this form if you have two or more insurance plans)
• Minor Patient Consent Form (complete this form only if the patient is 17 years old or younger and must be treated in the parent/guardian’s absence)

 

HIPAA Policies and Procedures – Notice of Privacy Practices (For all patients; please read and print a copy for your records).

 

In addition to your registration forms, please email (or bring with you):

• a government-issued photo identification card (we require everyone to be properly identified)
• all insurance cards – if you are insured (original cards; no paper copies),
• all pertinent medical records (including x-rays and test results) from other providers, and
• a form of payment (we accept cash and credit cards: Visa, MasterCard, and Discover; no personal checks accepted on the initial visit).

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