Patient Information Forms

What’s included in the packet

• Patient Information – your contact details, responsible party/policy holder, and insurance information
• Important Insurance / Payment Information and Assignment of Benefits
• Consent for Text Message and Email Reminders
• Patient Notice of Privacy Practices – including people we may speak to about your health
• Arbitration Agreement

Before you come in

• Print all pages and complete them in ink.
• Sign and date where indicated.
• Bring the completed forms with you to your appointment.

For your privacy, please do not email completed forms, since they contain personal and insurance information.