Forms

Patient Forms

Please read our Notice of Privacy Practices, which is standard patient privacy information. Next, print and complete ONE of the three Patient Registration Form that is appropriate to you. Print, read, and sign our Office Financial Policy to indicate you have agreed to our terms of payment. Finally, you can print and complete the Patient Health History Form which is necessary for your initial exam.

(You can download the Acrobat Reader if necessary)

Read-only Forms

• Notice of Privacy Practices
  This document is read-only.

Read and Sign Forms

• Office Financial Policy
  The patient or responsible party must sign to agree with our financial terms.

Choose and Complete One of These Forms

• Minor Patient Registration Form
  All patients under 18, or over 18 if still on parents' insurance. This is also the best form for young adults who are college age or otherwise still living with their parents and covered by their parents' insurance.
• Adult Patient Registration Form
  Patients over 18 and insured by self, spouse, or partner.
• Medicare Patient Registration Form
  Patients over 65 or disabled who have Medicare Part B coverage.

Complete This Form

• Patient Health History Form
  Health history quesionnaire for patient exam.

Optional / Miscellaneous Forms

• Authorization for Release of Medical Records
  This form authorizes the release of medical records to or from our practice.
• Consent to Treat Minor Patient
  This form gives permission and reviews responsibilities for us to treat a minor patient without the presence of parent or legal guardian.