Secure Intake Form

Please take a few moments to complete our secure Online Intake Form. This form has been developed to assist us to prepare in advance for your consultation and save you time filling out paperwork during your office visit.

Please be as complete as possible. Any items you are unsure of you may leave blank. We ask that one form be completed per each traveling individual.

This form will be encrypted and securely transmitted to us. All information received by us will be treated with the same confidentiality as all other medical information. If you prefer, you may also download and print the form ( Download Printable Version ), fill it out and mail or fax it to our office ( Contact Information ).

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Before you begin , please review and agree to the Health Information Portability and Accountability Act (HIPAA) disclosure form. Each adult individual must provide agreement to this form. Parents should agree for their minor children. You may be asked to sign an actual form during your first visit to our office. ( Download printable version )