New patients to our office are asked, at their first visit, to complete the following forms. We ask that you fill them out as completely as possible. If you prefer, you may download the forms here and complete them before your visit. If you chose to wait until you come to the office to complete these forms, we ask that you arrive at least 30 minutes before your scheduled appointment to allow enough time to complete this paperwork.
- A Signature on File form, which authorizes us to collect payment from your insurance company, or directly from you for any outstanding balances and/or treatments which are not covered by your insurance policy. The lower section of this form should be completed by Medicare recipients as well. Please note that we do need your signature on file in order to provide your care.
- A Patient information form, which provides us with information about you such as your name, address, telephone number(s), contact information (including email and emergency contact information), and your insurance information. Please fill out this form completely; the information not only helps us to properly submit claims to your insurance provider (preventing you from receiving unnecessary bills directly), but also gives us the information we need should we need to contact you for any reason.
- A Health History form. This form allows you to record your medical history, including medications, allergies, habits (for example smoking or caffeine intake), and hospitalizations, as well as any problems or symptoms that you are presently having. By filling out this information in advance, we can not only ensure that we have your complete medical history available, but also we are able to spend more time during your visit focusing on the reason for your referral to us and our recommendations for evaluation and treatment.
The forms can be downloaded in the following formats:
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