Before Your First Visit
The documents below are the same documents that you are required to complete during the registration process at your first visit. In order to save time during your visit, please feel free to print and fill in these documents. Please bring these completed forms, along with your photo ID, insurance card(s), and any medication and supplements you are currently taking in their original bottles with you to your appointment.
Patient Registration Form
Registration for New Patients or Patients that haven't been seen in 5 or more years
Patient Registration Form.pdf
Adobe Acrobat document [45.4 KB]
Registration for New Patients or Patients that haven't been seen in 5 or more years
Patient Registration Form.pdf
Adobe Acrobat document [45.4 KB]
Financial Policy Form
Please read and sign this form. Simply states that you are responsible for your bill and that we are permitted to bill your insurance.
Financial Policy.pdf
Adobe Acrobat document [47.0 KB]
Please read and sign this form. Simply states that you are responsible for your bill and that we are permitted to bill your insurance.
Financial Policy.pdf
Adobe Acrobat document [47.0 KB]
HIPAA Acknowledgement Form
This form states that you have read the HIPAA Notice of Privacy Practices on the HIPAA tab on this website and that you understand the information. Also, please designate the desired people you wish to have access to your medical information as stated on the form. Please Sign and Date.
Authorization for Release of Information - Compound Release. Who can have access to your medical information.
HIPAA Form New 2015.pdf
Adobe Acrobat document [349.2 KB]
This form states that you have read the HIPAA Notice of Privacy Practices on the HIPAA tab on this website and that you understand the information. Also, please designate the desired people you wish to have access to your medical information as stated on the form. Please Sign and Date.
Authorization for Release of Information - Compound Release. Who can have access to your medical information.
HIPAA Form New 2015.pdf
Adobe Acrobat document [349.2 KB]
Patient Medical History Form
Please fill in your/patient medical history as thoroughly as possible. Include the year of diagnosis or surgery and family history and relation to family member where applicable.
Patient History Form.pdf
Adobe Acrobat document [127.9 KB]
Please fill in your/patient medical history as thoroughly as possible. Include the year of diagnosis or surgery and family history and relation to family member where applicable.
Patient History Form.pdf
Adobe Acrobat document [127.9 KB]
Patient History Form (Side 2)
Please fill in this reverse side of the patient medical history form as thoroughly as possible.
back history formg.pdf
Adobe Acrobat document [261.0 KB]
Please fill in this reverse side of the patient medical history form as thoroughly as possible.
back history formg.pdf
Adobe Acrobat document [261.0 KB]
Authorization to Release Health Information
Please fill out this form if you have medical records from another doctor's office that you would like have sent to our office. This form can also be used for existing patients if they require us to send records elsewhere.
AuthorizationReleaseHealthInformationJan[...]
Adobe Acrobat document [81.6 KB]
Please fill out this form if you have medical records from another doctor's office that you would like have sent to our office. This form can also be used for existing patients if they require us to send records elsewhere.
AuthorizationReleaseHealthInformationJan[...]
Adobe Acrobat document [81.6 KB]
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