Full Patient Packet

The privacy of your protected health information is important to us. Please confirm we have provided you with a copy of our Notice of Privacy Practices.

To protect your privacy, we need your written permission to leave detailed telephone messages on your answering machine, voicemail system, or with a person you designate.

Consent to release confidential health information about me by releasing a copy of my medical records, a summary, or a narrative of my protected health information to the physician(s) or facility.

This allows us to administer necessary treatment, understand how my medical information will be used and shared for care and insurance purposes, and accept financial responsibility for any charges not covered by insurance.

Use this form to provide us with your medical history.