Patient Registration Forms & Privacy Notices
If you are a new patient, please fill out the forms listed below in advance of your appointment to assist the staff in making sure that we have all the information necessary to provide you with quality care and treatment. Please bring the completed forms with you to your appointment.
New Patient Registration Forms
- Patient Registration
- Patient Consent
- Assignment of Benefits
- Patient Information
- Privacy Acknowledgement and Disclosure Agreement
- Patient Consent to Email or Text Usage
A medical release waiver must be signed in order to obtain a copy of your medical records or to have them sent to another health care provider. If you are requesting that your records are sent to another provider we ask that you supply us with their name, address, and phone number.
We charge $10.00 per page for forms that need to be completed, $20.00 for the first 40 pages that need to be copied and $.25 per page after the first 40.
Patient Rights & Responsibilities
We respect our patients’ dignity and pride. This document will explain your patient rights and responsibilities. It is part of your patient registration and is an important part of your health care plan.
This privacy notice describes how health information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
- Notice of Privacy Practices (provided for you at your first visit)
- Aviso Sobre Las Practicas De Privacidad (proporcionada por usted en su primera visita)
These forms require Adobe Reader. If you do not have Adobe Reader, you may download it free here: