For shorter wait times, please complete and bring the appropriate forms to your first appointment.
Please indicate “N/A” or “None” when a section does not apply to you.
NEW PATIENT FORMS
- Adult History
- Child History
- Financial Policy
- Patient Information Form
- Procedure Consent Form
- HIPAA Notice of Privacy Practices
- Acknowledgment of Receipt of Notice of Privacy Practices
INFORMATION TO HAVE ON HAND:
Be advised, if any of the required information listed below is missing it may be necessary to reschedule your appointment until it is available to you.
- Insurance card(s)
- Valid driver’s license or government-issued photo ID
- Insurance policyholder information — this is the person who holds the policy under which you are covered.
- Policy holder’s name
- Social security number
- Date of birth
- Name of policy holder’s employer (if applicable)
COPAYS & DEDUCTIBLES:
- Please be aware of your insurance co-pay, deductible, and coinsurance.
- Specialist co-pays may not cover all diagnostic services performed in the office. Please contact your insurance carrier to determine individual benefits.
All co-pays, deductibles, and coinsurances are collected at the time of your visit with no exceptions!
- Obtain an authorization or referral if required by your insurance. Please contact your insurance company or primary care physician for more information.
- Bring any pertinent medical records pertaining to your visit such as scans or test results. This is helpful to diagnose and treat your condition.