Downloadable Forms

New Patients

Listed below are the forms that new patients of this practice are required to fill out.

• Patient Registration Form
• HIPAA Disclosures of PHI
• Payment Policy
• Privacy Policy
• Health History for Pediatric New Patient (Age 0-5)
• Health History for New Patient (Age 6 and up)
• Medication Reconciliation Form
• Consent by Proxy (if needed)
• General Patient Consent for Care

Established Patients

We require our established patients to update the following forms at least annually.

• Patient Registration Form
• HIPAA Disclosures of PHI
• Payment Policy
• Privacy Policy
• Medication Reconciliation Form

You may download and complete these to save time on your appointment day if you wish.

Sports Physicals

For all young athletes, please complete the following forms and bring to your appointment.

• MHSAA Sports Physical Form

All Patients

Please bring the following to your appointment:

• Completed forms mentioned above
• Current Health Insurance Card(s)
• Drivers License or State Issued I.D.
• Current Medications
• Immunization Record for minor children

Important Information

A parent or legal guardian must be present at the initial new patient appointment for a minor child. Legal guardian must have court issued papers to validate guardianship. The Consent by Proxy form, listed above, may be completed by the parent or legal guardian for any future appointments.

Payments of co-pays, deductibles, or cash balances are due at the time of service. We accept Visa, MasterCard and Discover credit or debit. We also accept on-line payments on this website located under the Payments tab.