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Patient Forms
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Non-Discrimination Policy

Below are links to forms that are used by our office.


Auth for contacts.docx

The above form needs to be filed out if you would like anyone to be able to access your medical information such as a family member or friend. We are not allowed to discuss anything pertaining to your medical information without having this signed form on file. Information to be discussed includes appointment times, billing information, and health information.


pt release[1].doc

The above form needs to be filled out if you would like us to fax or mail a copy of your records to an outside source. For instance if you are needing records sent to another doctors office, insurance company, or another source this if the form you would fill out. We need to know what information you are needing send including type of record and dates of service, we also need to know where to send the records to. Bring or fax this form to our office and we will send your records out within two weeks of receiving this form.


Pt qustionaire.docx

The above form needs to be filled out by new patients in our office. This form gives us a background of your past medical history so that we can be aware of what has been done in the past and the problems that you are currently having.

                   English                                                                    Español


Office and Financial Policy.doc

 Office and Financial Policy spanish.docx

The above documents are our Office and Financial Policy in English on the left and Spanish on the right. These explain all of our office policies as well as our financial policies. Please read the above notice and sign the form below indicating that you read and agree to our policies.

Signature and authorizattion page.docx

 Signature and authorizattion page-Spanish.docx

The above form is our signature page indicating you have read and understand our office and financial polices, as well as agreeing for us to treat you and use your information to bill your insurance for services rendered. It is an acknowledgement of receipt of notice of privacy practices for our office.This form must be signed and on file at our office before you receive treatment.

If you are in need or a different form or would like more information please contact our office.