Please fill this form as accurately as possible as any error may result in a delay in scheduling.
Please read the clinic policies very carefully before signing. All patients must provide their consent for treatment, communications (calls, emails, and text messaging), and agreement of financial responsibility.
This policy describes how health information about you (as a patient of this Care Center) may be used and disclosed, and how you can get access to your individually identifiable health information. Please review this notice carefully.
This policy describes the process for the documentation, maintenance, and transmission of information using virtual visit technology.
This form allows patients to authorize the disclosure of their health information to a designated individual, company, agency, or facility.
We kindly request our patients for a credit card that may be used to pay any copay, deductible balance that may be due on your bill, No show fee, etc. Your credit card information will be obtained and kept securely. This “Card-on-File” program simplifies payment for you and eases the administrative burden on your provider’s office. It reduces paperwork and ultimately helps lower the cost of healthcare. If you have any questions about the card-on-file, payment method, please do not hesitate to let us know.
Please fill in as much information as possible, this will help the provider to review your medical information and assist in the formulation of a better treatment plan.
Please fill in as much information as possible, this will help the provider to review your medical information and assist in the formulation of a better treatment plan.
Please fill in as much information as possible, this will help the provider to review your medical information and assist in the formulation of a better treatment plan.
Please fill in as much information as possible, this will help the provider to review your medical information and assist in the formulation of a better treatment plan.