The forms listed below are required for new Clinic patients and must be completed on first visit, prior to any treatment starting. The forms labelled as Sign & Return must be printed out, signed and submitted upon the Patient’s initial Clinic visit. If a printer is not available, consider visiting your local Public Library (where printing is done free, or for a nominal charge), or a nearby OfficeMax.

Form Name
What do I do?
Link to...
Welcome Letter
General statement of purpose
Clinic Privacy Practices Policy
Clinic's use of your personal information, including your Patients' Rights
Acknowledgment of Privacy Practices Policy
Acknowledment that Patient has received Clinic's Privacy Practices Policy
Sign & Return
Electronic Communications Agreement
Communications consent form
Sign & Return
COVID-19 Consent Form
Acceptance of risk associated with COVID-19
Sign & Return
New Patient Intake Form
General patient information, including personal details, medical and familial history
Sign & Return
Cancellation Policy
24-hours notice is required in order to cancel an appointment without assessing a $45 fee. Review for more details.
Sign & Return
Arbitration Agreement
Bindign arbitration agreement, should the situation require such remedies.
Sign & Return
Consent for Use and Disclosure
Pertaining to the use of protected health information, payment activities, and healthcare operations.
Sign & Return