Patient Forms
What WE NEED before your Appointment
Please download, print and Sign the forms below before your first appointment
New Safety Rules for Covid-19
Masks will be worn during the duration of the time in the building
- All patients are staggered with a minimum of 30 minutes between each patient
- Temperature checks will be conducted upon arrival
- Come alone, the waiting room is currently closed. If you need a ride, please arrange to be dropped off and picked up at the door
- All used surfaces are sanitized before and after each patient
- Table paper will be used and disposed of after each patient
- Do NOT come in if you are feeling sick and/or are having flu like symptoms
If you have travelled from out of state we ask that you schedule no earlier than 14 days upon return, following any quarantine requirements as per the local and state health department
Until further notice, we will not be scheduling patients confirmed with COVID, or those who have been in recent contact with a confirmed case.
ALL patients MUST complete this form at this time
Privacy Notice
I make every effort to keep your personal and medical information confidential.
- Your name, contact information, and medical information are seen by your practitioner only.
- Your medical information is kept in a file and is only accessed by me in order to make medical decisions and to document your treatments.
- I will not provide information from your chart to anyone unless specifically requested by you in writing.
- I will not discuss your case with anyone, including your family members and other medical providers.
Patient Intake Form
ONLY NEW PATIENTS must fill out the intake form, providing their name, address D.O.B, and emergency contact details.
Cancellation Policy
- There is a 24 hour cancellation policy.
- In the event you miss your appointment or cancel with less than 24 hours notice, you will be charged for the appointment.
- I understand urgent situations come up. Please call or text me to discuss any cancellations due to illness, injury, or other emergencies.
- Please contact me if you have questions about appointment times.