Forms Required by All New Patients

New Patient Verification Form

I understand that the first visit is an extended consult plus treatment which requires a considerable time commitment of 1.5-2 hours. Because of this, any cancellation of the initial visit within 12 hours or a No-show will be charged a fee of $50 prior to rebooking any future appointments.

If you wish to use insurance for your visit please fully complete the remainder of the form. Otherwise please complete the required fields and then click on the submit button on the bottom of the page.

By checking this box I understand and acknowledge the clinic's initial appointment cancellation policy
** We cannot bill Medicare or Medicare supplemental**
This is often found on the back of the insurance card

Health History and Policy Forms — Please print one sided only and complete; if not using insurance please disregard insurance information on last page. If you can not print and complete these forms prior to your visit please arrive at least 25-30 minutes early to allow enough time to complete them before your scheduled appointment. This will ensure that we begin your visit on time!

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