Reason For Visit

    Your Gender*

    Patient First Name*

    Patient Last Name*

    Patient Email*

    Patient Date of Birth*


    Primary Health Insurance*

    Secondary Insurance Company*

    Plan Number*

    Group Number*

    Insured’s Employer/School*

    Insured Date of Birth*

    Insured’s Name* (as it appears on insurance card or ID)*

    Relation to Patient*

    Insured’s Phone Number*

    Who’s your current Primary Care Provider?* ( if your insurance plan doesn’t require one., not required per plan)

    Insured’s Address

    Primary Care Physician*

    Patient Mobile*

    May We Text You Test Results / Follow Up Info?


    I, the undersigned, consent to the care and treatment by the attending physician and his/her associates or assistants.
    I understand the treatment includes customary procedures such as blood draw, incision and drainage, suturing, splinting and others. I acknowledge that no guarantees have been made as to the effect of such treatment.


    I acknowledge full financial responsibility for any service rendered and I understand that the payment of charges incurred in this office is due at the time of service. I assign insurance benefits to this office and I also understand that the charges not covered by insurance remain my responsibility.

    HIPAA Privacy Notice

    We and our affiliates, employees and agents, may use and disclose protected health information (e.g., information relating to the diagnosis, treatment or billing which identifies patient's name, address, social security number) for the purpose of your treatment and share your PHI with other providers involved in your care.

    We use SureScripts, Inc., a system that allows prescriptions and related information to be exchanged between our providers and the pharmacy. The information sent between these systems may include details of any and all prescription drugs taken currently and/or in the past.

    We may use and disclose PHI to help resolve insurance claims and health benefit coverage issues such as prior authorizations of medications, specialist referrals etc...

    We may use and disclose PHI to support our Health Care Operations. These activities include but are not limited to performance reviews, employee training and quality assessment tasks. For example, we use sign-in sheet where you are asked to leave your first name and we may also call you by your name in the waiting room our staff is ready for you.

    We may disclose PHI when required by the law for public health purposes such as mandatory reporting of communicable disease, abuse and neglect etc...

    You may refuse to sign this notice. Your refusal to sign will not affect your eligibility for benefits or enrollment or payment for or coverage of services.