Forms

Dear Prospective Patient

1. I need these forms completed, signed, and received before your 1st appointment

2. Please fill in the forms only with a black or blue inked pen and write as legibly and as completely as possible 

3. Please do not write anything in boxes at the right upper corner of the forms

4. " Notice of Privacy Practices" is only for your review. You do not need to sign it, print it out, or send it back to us

5. Otherwise you need to complete and sign the other forms 

6. In "Outpatient Medication Consent" form the only part you need to complete and sign is the mid-section of page four (4). Obviously, I will discuss and obtain your verbal consent before starting you on any medication. The purpose of this form is not to include your current medications or medications you wish to be on them 

7. When done, you can either scan the completed and signed forms and email them back to me, or mail them to my office address if you believe that I can receive them before your 1st appointment 

Thanks

1. Consent and Financial Agreement

2. Credit-Debit Card Authorization

3. Notice of Privacy Practices

4. Outpatient Medication Consent

5. Receipt of Privacy Practices Notice