Clinic Forms

Patient Intake – Long Form

With this form you will become an established patient at the clinic. It gives me all your medical information. Please use additional paper if you want me to have that at the appointment, like your history with specific medical condition.

Size: 1.2 MB
Version: 1.0
Published: November 18, 2021
Patient Intake – Short Form

This form is only for acute problems that will take a short visit to deal with, like ear infection, cold or so on.

Size: 106 KB
Version: 1.0
Published: November 18, 2021
Pediatric Intake Form for Age 0-5

Newborns and expecting mothers.

Size: 832 KB
Version: 1.0
Published: November 18, 2021
Pediatric Intake Form for Age 6-18

Young children and teenagers have special needs related to the rapid growth they experience.

Size: 1.1 MB
Version: 1.0
Published: November 18, 2021
HIPPA Form 2022

Please take your time to read this form as it relates to your right to privacy. Note: there is no need to print this form out.

Size: 167 KB
Version: 1.0
Published: November 18, 2021
Policies (Phone calls, cancellations and HIPPA)

Please print this form out and bring it to your appointment so we can include this with your file.

Size: 7 KB
Version: 1.0
Published: November 18, 2021