Patient Intake


Intake Form

  • Patient Information

  • Responsible Party Information

  • Insurance Company Information

  • Primary

  • Secondary

  • I have completed this form accurately and completely. I certify that I am the patient or the legal representative of the patient. I understand that full payment is due at the time of treatment, unless arrangements are made otherwise. I agree to pay any amount not covered by insurance. I authorize the release of any information necessary to process insurance claims.

    Medicare Only: My signature requests that payment be made to physician. I am responsible for deductible, coinsurance and non-covered services only.