Important Forms
Our patients are our favorite people.
While we have these forms available for your convenience, keep in mind that appointments are required to join our program.
Sliding-Fee-Scale Program Patients
-
Patient Guidelines (175 KB)
New Patients – Required Forms
- Patient Application (153 KB)
- One for the family
- Contract for Participation (88 KB)
- One per adult
- HIPAA Release of Information Form (260 KB)
- One per person
- "How are you feeling?" Form (451 KB)
- One per adult
- Authorization to Disclose Protected Health Information (178 KB)
- One per person
- Health History (67 KB)
- One per adult. Already included in application of first adult.
New and Renewing Patients – Extra Forms
- Profit/Loss Form (100 KB)
- If you are self-employed
- Residence Confirmation (176 KB)
- If you don't have a lease or mortgage statement
- Confirmation of Paid Living Expenses (364 KB)
- If friends or family members help you with bills or other living expenses
- Email Consent Form (122 KB)
- If you’d like us to be able to contact you by email
Renewing Patients
- Renewal Application (141 KB)
- One per family
- Contract for Participation (88 KB)
- One per adult
- "How are you feeling?" Form (451 KB)
- One per adult
- Authorization to Disclose Protected Health Information (178 KB)
- One per person
- HIPAA Release of Information Form (260 KB)
- One per person
For more information about getting started, call (720) 458-6172.
