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 | Purpose | What do I do? | Link to... |
Welcome Letter | General statement of purpose | Read | |
Clinic Privacy Practices Policy | Clinic's use of your personal information, including your Patients' Rights | Read | |
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 and Informed Consent Agreement | Binding 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 |