Patient Information Form

Please correct the errors described below.

Add Additional Medications

Personal Medical History

Family Medical History

Additional Family Medical History Entry

Social History

(Days per week/intensity/etc.)

Surgical History

Additional Surgeries

My signature below acknowledges that I was offered the opportunity to view the office’s privacy policy regarding my medical records (HIPAA) and that I authorize evaluation and treatment by the physician. I also authorize the office to submit claims directly to my insurance company. I also acknowledge that I am responsible for all deductibles and/or copays as per my insurance guidelines. ***Please note that you cannot be seen by the physician until this form is signed as it is consent for treatment.***

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Your information will be encrypted.