We know that your time is very valuable. In order to allow for the fastest processing during your first visit to our office we request that you take the time to fill out these forms in the comfort of your own home.
All forms are available via DocuSign or Adobe Acrobat PDF.
If you choose to use the PDF, please download and fill out the necessary form(s), save them to your desktop, then print the forms and bring them on your first visit. Get Adobe Acrobat Reader
NEW PATIENT INTAKE FORMS
This package contains all the forms needed by a new patient.
- Patient Registration Form
- Financial Policy Form
- Payment Authorization Form
- Authorization of Release of Information
- Medicare Advance Beneficiary Notice
- Hippa Privacy Notice
During the COVID-19 pandemic, there is some increased risk for patients who visit a healthcare provider. Some patients have a higher risk of complications from COVID-19. Please review and sign the COVID-19 WAIVER prior to treatment.
MEDICAL RELEASE TO YOUR PHYSICIAN
We need your authorization in order to share your medical records with your primary care physician. Please be sure to list the name and address of the recipient of your medical information.
MEDICAL RELEASE TO SALEEBY & WESSELS
We need your permission to collect your medial information from your primary physician or specialist. Please complete and sign.