Patient Forms

To help reduce your total time at our Center, please download and complete all the applicable registration forms listed below prior to your appointment and bring these with you on the day of your appointment. You may also complete forms when you arrive at our Center – for this option, please arrive an additional 30-45 minutes prior to your appointment.

In addition to your registration forms, please 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).

 

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

  • All patients: Complete the forms: “Patient Registration Form;” “Medical History Form;” “Notice of 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).
  • Dr. Cook patients: Complete all forms titled “Dr. Cook -…” (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 “Consent to Consult and Treat Minor Form” is completed. In addition to completing this form, please see our staff for additional details.

Forms:

 

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

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