Our preferred way to receive your New Patient Forms is through our online, HIPAA-compliant secure form submittal system. Please click on the appropriate form below to complete and send:
New Adult Patient
New Pediatric
Patient
Birth to 1 Year
New Pediatric
Patient
1 to 4 Years
New Pediatric
Patient
5 to 10 Years
New Pediatric
Patient
11 to 17 Years
Medical Record Release and Disability/FMLA Forms
We have partnered with MediCopy to fulfill Release of Information requests and disability/FMLA forms. MediCopy is fully HIPAA-compliant and adheres to all state and federal regulations concerning the release of medical information.
Medical Records
Patients
To request your medical records please visit MediCopy.net/Patients
Please provide an email address on the authorization to expedite the process and delivery method. Records sent via email, or to another provider, are complimentary.
Third-Party Requesters
To request medical records please visit MediCopy.net/ThirdPartyRequesters
Disability/FMLA Forms
To submit FMLA/Disability forms, please visit MediCopy.net/Forms
Forms are $45 for the first form and $15 for each additional form turned in at the same time. After payment is received, Disability/FMLA forms are completed within three (3) business days.
If you have any questions, please contact MediCopy:
online chat: MediCopy.net | phone: 866-587-6274
Medical Record Release
Medical Record Release
Spanish
If you’re not able to securely send your New Patient Packet, you may print it or any individual page below and bring with you to your appointment
Click on any form icon below to download an Adobe Reader® file of that form. Where applicable, print, fill out and bring the completed forms with you at your next appointment.
ALL NEW PATIENTS MUST BRING COMPLETED FORMS WITH THEM TO THEIR FIRST APPOINTMENT AND ARRIVE 15 MINUTES EARLY. IF YOU DID NOT COMPLETE YOUR PAPERWORK IN ADVANCE PLEASE ARRIVE 45 MINUTES PRIOR TO YOUR SCHEDULED APPOINTMENT TIME TO FILL OUT YOUR PAPERWORK. IF YOU DO NOT HAVE YOUR FORMS COMPLETED AT YOUR SCHEDULED APPOINTMENT TIME YOU WILL BE ASKED TO RESCHEDULE YOUR APPOINTMENT FOR ANOTHER DATE.
New Pediatric Patient –
Birth to 1 Year
New Pediatric Patient –
1 Year to 4 Years
New Pediatric Patient –
5 Years to 10 Years
If you don’t have Adobe Reader on your computer, click here for a free download 