CLINIC FORMS

Please arrive 15 minutes prior to appointment time, so that we can prepare the chart and collect insurance information.

 

Co-pays are required upon clinic visit, and patients without insurance are required to pay the full bill at the time of their first visit.

 

The following forms should be printed and filled out as required. Then snail-mailed, faxed, or brought in with you to the clinic at appointment time.

 

Patient Registration

To register as a patient at the clinic, please fill out the Patient Registration form (pdf).

 

Privacy Act

Please fill out our Privacy Act form (pdf), required by law.

Privacy Policy Statement (pdf)
Notice of Privacy Practices (pdf)

 

Partnership Plan

Please fill out our Partnership Plan form (pdf), which emphasizes the interactive relationship between us and each patient.

 

Medical History

Please fill out our Medical History form (pdf), and our Health Screen form (pdf), outlining your current medical condition and prior medical history.

 

Epworth Sleepiness Scale

Epworth Sleepiness Scale form (pdf)