New Patient Form

Instead of completing the on-line form below you can use the printed forms which do not qualify for the 50% savings on your initial exam – to get the printed forms either click here to download the New Patient Forms PDF or visit us when we are open and we will give you the printed forms.

New patients, SAVE 50% on your initial exam when you complete and send the following on-line form!!

New Patients Welcome!
Pay as you go – No contracts
Service fees covered with most extended health plans
Doctor referral NOT required
Confidentiality assured

HEALTH INFORMATION

HEALTH CONDITIONS

Below is a list of conditions which may seem unrelated to the purpose of your appointment. However, these questions must be answered carefully as these problems can effect your overall diagnosis, treatment plan and possibility of being accepted for care.

Check any of the following you have had in the past 6 months

Females Only

CURRENT HEALTH COMPLAINTS

List up to 3 complaints below and answer the following questions regarding each. List your primary complaint as #1.

1d. Rate intensity of this problem: (1 = mild; 10 = extreme)

2d. Rate intensity of this problem: (1 = mild; 10 = extreme)

3d. Rate intensity of this problem: (1 = mild; 10 = extreme)

LIFESTYLE AND SOCIAL HISTORY

ADDITIONAL INFORMATION

PERSONAL INFORMATION

ACCOUNT INFORMATION

Please wait for confirmation message after clicking the send button - if you don't see a confirmation, chances are you have not provided all the required information, please scroll up and resolve any error messages before clicking the send button again.