Please correct the errors described below.

(Your will be receiving an appointment reminder call 1 day prior to your appointment. Please be sure we have the correct telephone number to contact you and/or leave a message).

Our medical staff and office personnel want to take this opportunity to acquaint you with our office policies in order to make your visit with us as pleasant as possible. We are committed to providing you with the finest in personal service and healthcare.


Please complete the enclosed new patient visit forms (8 pages) and bring the completed forms with you to your appointment. If it is more convenient you can mail in the completed forms. Please answer all questions.


Office hours are appointment only. Appointments can be scheduled on Monday, Tuesday and Thursday from 9-4 PM and Friday from 9-3:00 PM. We are closed on Wednesdays. We ask all New Patients to arrive at least 15 minutes prior to your scheduled appointment to facilitate the registration process. Our goal is to allow the appropriate amount of time for each patient. However, sometimes a particular case is more complex than anticipated and more time may be required. We ask you patience and understand that scheduled appointment times are approximate. If you are unable to keep your appointment please call (203) 238-3668 at least 24 hours in advance to reschedule. There will be a fee of $50.00 for appointments not cancelled with appropriate notice.

REFERRALS and COPAYMENTS (for HMO and Managed Care Patients):

If your insurance is an HMO or other managed care plan which requires a referral for a specialist visit, it is your responsibility to get the referral from your primary care physician. Please have the referral made out to Dr. Tina Boucher. Co-payments are due at the time of visit. We do not bill for co-payments. For your convenience we accept credit cards, checks and cash.


We strive to see patients on time. Arriving late for an appointment may require rescheduling. Every effort will be made to accommodate you with a rescheduled appointment.


Prescriptions are filled at the time of your appointment. If a refill is required at another time please have your pharmacy fax us a written request to (203) 238-3670. Please allow 24-48 hours call back time for refills. Prescriptions requested after hours will be reviewed on the next business day and be processed as stated above. If you have not been seen in a year or more, your prescription will not be filled. You will need to make a follow up appointment.


Insurance Information (please present insurance card at time of visit)

**Insured is the name of the person who carries the insurance, not always the patient**

Referring Physician

Primary Care Physician

I authorize the release of medical information to my primary care or referring physician, to consultants if needed and as necessary to process insurance claims, insurance applications and prescriptions. I also authorize payment of medical benefits to the physician.

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

Review of Symptoms (Please check all that apply)

Female Reproductive

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