• Patient information

    Please complete the form to the best of your knowledge. The more complete this form is the shorter your check in time will be.
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  • Primary Insurance

  • Policy Holder Information

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  • Secondary Insurance

  • Policy Holder Information

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  • PLEASE LIST ANY OTHER PARTIES WHO CAN HAVE ACCESS TO YOUR HEALTH INFORMATION:

    (This includes step parents, grandparents and any care takers who can have access to this patient’s records):
  • In signing this HIPAA Patient Acknowledgement Form, you acknowledge and authorize, that this office may recommend products or services to promote your improved health. This office may or may not receive third-party remuneration from these affiliated companies.

    We, under current HIPAA Omnibus Rule, provide you this information with your knowledge and consent.


  • Patient Information

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  • Previous Surgeries

  • Previous Procedures

  • Review of Systems – Please select any symptoms you are currently having

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  • Social History

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  • Medication List

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  • Please complete the information below and bring this form with you to your appointment.


    List all current medications that you currently take, including vitamins, over-the-counter medications, and herbal preparations. Make sure to include dosage and frequency

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  • Please fill out the pharmacy information completely, this information is used to electronically send your prescriptions.

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  • *****The above information is complete, true and correct to the best of my belief.*****

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  • Should be Empty: