Forms

New Patient Registration Packet

If you are a new patient of ours, we welcome you to fill out the necessary paperwork ahead of your appointment. (This really speeds up your check-in at the time of your appointment and can help you see your doctor even faster!)

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Sliding Fee Application

We are so happy to offer a sliding fee discount program to eligible individuals based on the patient’s ability to pay.  Ability to pay is determined by the household size and annual income relative to a discount schedule based on federal poverty income guidelines.

If you would like to apply, please fill out the following application:

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3rd Party Release of Health Information

If you would like a 3rd party to be given the permission/ability to discuss your healthcare with our staff, please fill out the following form. (Note: If you are a new patient, this form is already included in your registration packet.)

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Authorization to Release Health Information

Unlike the 3rd party release form, the Authorization to Release Health Information form is a form that releases health information from your medical record; whether that be to someone in your family or another medical institution. (Note: if you are a new patient, this is not included in your patient registration packet.)

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