MedicalForms

Patient Forms

The following forms help us gather the information necessary for your first visit.  They can be filled in on your computer and then printed out. Simply click the link, open the file, fill in the information blanks and print it out.

Please complete our New Patient Demographic form and Medical History form and bring them to your initial visit.  At that time, we will photocopy your insurance and your government-issued Photo ID and return them to you.

REFERRALS

Some insurance companies require a referral for you to see one of our Specialists.  It is your responsibility to obtain it from your Primary Care Physician. Examples of these insurances are:  Tricare Prime, United Healthcare/MDIPA and Aetna HMO.

CO-PAY

If your insurance indicates a co-pay for your office visits, we will collect this at the time of check-in at every visit.  If we have to bill you for your co-pay, you will be responsible for an additional $25.00 service charge.

CANCELLATIONS, RESCHEDULES AND MISSED APPOINTMENTS

We require notification of least 24 business hours in advance if you are unable to keep an appointment, in order to offer that appointment to another patient who needs care.  Failure to give us a 24 business-hour notice prior to your appointment will result in a $50.00 fee that is not covered by your insurance and is subject to collection.


If, for any reason, you are unable to complete the form in this way, we will assist you with the forms at the office.  As always, please ensure that your arrive at least 15 minutes early for your appointment.