New Patient Forms

Many of the required forms you will be asked to complete at your first visit are available here for download and printing. They may be completed prior to your arrival and hand carried to your first visit.

Note:  All forms require Adobe Acrobat Reader to view.

Notice of Privacy Practices and Acknowledgement Receipt
Assignment of Benefits
Communication Policy and Waiver
Release of Information
Health History Form
Detailed Health History Form  (For Dr. Leibach, Dr. Bank, Dr. Lafollette,
          and Dr. Ortiz patients only)
Financial Auth Policy and Acknowledgement Receipt