New Patient Forms

On this page you will find all of the forms needed to begin services.

Please download, fill out, and bring with you these forms on your first visit.

In addition, on your first visit please remember to bring the following:

• Your insurance card 
• Visit co-payment (cash, check or credit/debit card)
• An updated list of all medications you are currently taking (including over-the-counter and herbal supplements), the dosage, and how often you take it.

IF SEEKING MEDICATION MANAGEMENT

If it has been over a year since you have seen your PCP, or you do not currently have a PCP, I will ask you to have an appointment scheduled with a PCP prior to our first appointment together.

Forms:


Patient Information and Consent to Treatment

Patient Registration

Health Insurance Portability and Accountability Act (HIPAA) agreement

Release of Information

Telehealth Consent
​


HIPAA, or the Health Insurance Portability and Accountability Act, is a federal law that regulates how your health information is accessed, stored, shared, and protected, as well as your rights as it pertains to your health information. More information about HIPPA can be found here: www.hhs.gov/hipaa/for-individuals/index.html 

You may need Adobe Reader to open and read these documents. You can download it here:  http://get.adobe.com/reader