New Patient Form

I understand that I am entitled to a copy of this notice upon request. I have reviewed, or been made available a copy of the notice of Privacy Practices regarding HIPAA policies. I understand that my medical records are confidential and that by signing this form I am allowing my information to be released to my insurance company upon request. I hereby authorize payment of health insurance benefits. I also authorize access to my medical records to the person(s) listed.

Our office observes a strict ‘no show’ appointment policy. Failure to arrive within 10 minutes of your scheduled appointment will result in a ‘no show appointment’ and you may need to reschedule to another time. We understand that sometimes a scheduled appointment cannot be kept, however we kindly request that you notify our office at least 24 hours in advance to cancel or reschedule your visit. If you do not show for your appointment, we will consider this in violation of our agreement and you will be charged a fee of $35 for the missed appointment.