New Patient Intake Forms

Please Fill Out the New Patient Form Before Your First Office Visit

The new patient form consists of three parts that must be completed before you can see the doctor. The form consists of:

  • New Patient Health History
    This section asks for your contact information, details regarding your insurance plan (if you have insurance), your current and past health issues, and your lifestyle/habits.
  • Privacy Practices Acknowledgement: HIPAA
    This section asks you to acknowledge (by your signature) that you have received and reviewed our Notice of Privacy Practices. This document explains our privacy policy and how we safeguard your protected health information (PHI).
  • Patient Payment Agreement
    This section asks you to agree to our payment and credit policies.
New Patient Forms

Receive the forms via E-Mail

New Patients Often Seen the Same Day. Call Us at (616) 453-0600.