*** READ CAREFULLY BEFORE SIGNING ***
Accepted applicants will be notified via phone call and must schedule new patient appt upon notification. After 3 failed contact attempts, applicants will be removed from the accepted list and will need to reapply. Accepted patients are required to maintain compliance with their annual wellness visits as directed by your provider, as well as with practice policies. Rejected applicants will be notified via e-mail. Per office policy, we do not accept patients with a long-standing history of controlled medication use, including, but not limited to, opioid pain medications such as hydrocodone, tramadol, oxycodone or any other opioids and benzodiazepines like diazepam (Valium) and lorazepam (Ativan). Inaccuracies in reported controlled medication usage will result in immediate discharge from the practice. I agree that all the above information is accurate, true, and current as of the date below. I understand and acknowledge that misrepresentation of medications and health history may result in an automatic discharge from the practice.