Patient Forms
Download and complete forms before your visit to save time.
To ensure efficient care and accurate records, please complete the required forms before your appointment. Forms can be downloaded, printed, and completed at home, or filled out upon arrival at our facility. Required forms are marked with an asterisk (*).
Complete Forms Online
For your convenience, registered patients can complete all forms securely through our Patient Portal. This eliminates the need for paper forms and ensures your information is directly entered into our system.
Access Patient PortalNew Patient Forms
New Patient Registration Form*
Complete for your first visit
Medical History Questionnaire*
Comprehensive health history
Insurance Information Form*
For billing and coverage verification
Emergency Contact Form*
Contact information for emergencies
Consent Forms
General Consent for Treatment*
Authorization for medical treatment
HIPAA Acknowledgment*
Privacy practices acknowledgment
Telehealth Consent Form
For virtual consultation services
Bioresonance Therapy Consent
Informed consent for alternative therapy
Financial Forms
Financial Responsibility Agreement*
Payment terms and conditions
Financial Assistance Application
For sliding scale fee qualification
Payment Plan Agreement
Extended payment arrangements
Insurance Assignment Form
Authorization for direct billing
Authorization Forms
Release of Medical Records
Authorize sharing of health info
Authorization for Minor Treatment
Parent/guardian consent for minors
Designated Representative Form
Appoint someone to act on your behalf
Advance Directive Registry
Living will and healthcare proxy
Form Completion Instructions
Before Your Visit
Download and complete all required forms. Bring them with you to your appointment along with a valid photo ID and insurance card.
Arrive Early
If you cannot complete forms at home, please arrive 15-20 minutes before your scheduled appointment to allow time for paperwork.
Bring Your Medications
Bring a list of all current medications, including over-the-counter drugs and supplements, or bring the medication bottles.
Insurance Information
Bring your insurance card and be prepared to pay any applicable copays or deductibles at the time of service.
Special Circumstances
Minors (Under 18)
A parent or legal guardian must complete all forms for minor patients and be present during the visit (except where state law permits minor consent).
Language Assistance
Forms are available in Spanish upon request. Free interpreter services are available for other languages. Please notify us in advance of your needs.
Assistance Needed
If you need help completing forms due to a disability or other reason, please contact us and we will provide assistance.
Need Help?
If you have questions about which forms to complete or need assistance, our staff is happy to help.
Patient Services
Phone: (725) 287-7791
Mon-Fri: 8am-6pm
Sat: 9am-2pm
Medical Records
Email: [email protected]
Fax: (702) 555-0101