New Patient Forms
Prior to your appointment, please print the following new patient forms. Carefully read through each form, fill in all of the necessary information and sign each form where indicated. If you have any questions, please call our office at (919) 841-1720.
Please Note: Form #7 is the HIPPA Disclosure Notice of Privacy Practices. This form is a copy for your records. You do not need to print or sign Form #7. However, for our records, you do need to print and sign Form #6, which acknowledges that you have read and understand the HIPPA Disclosure Notice.
REMEMBER to bring your referral slip, all seven (7) completed and signed new patient forms, X-rays and insurance information with you to the initial consultation.
- Form #1: Patient Registration Download
- Form #2: Payment Options Download
- Form #3: Patient Health History Download
- Form #4: Photographic Release Download
- Form #5: Authorization for Release of Information Download
- Form #6: Receipt of Notice of Privacy Practices Download
- Form #7: Notice of Privacy Practices Download
- Form #8: Medicare Claims Contract Download
You will need Adobe Reader to view the Forms.
Important Information for New Patients
To help protect you from becoming a victim of identity theft, our practice will verify the identity of all new and returning patients of the practice.
Additionally, federal law requires all healthcare providers to obtain, verify, and record information that identifies each new patient.
What this means for you: When you fill out your paperwork with us, we will ask for your name, address, date of birth, and other information that will allow us to identify you. We may also ask to see your driver’s license or other identifying documents.
