Patient Questionnaire

In order to facilitate your appointment and minimize any delay in your visit, the patient questionnaire is available for download. All new patients, and any returning patient with a new problem, need to complete the questionnaire. Thank you in advance for your cooperation.

The form must be printed and filled out by hand. In the future, you will be able to enter this information securely and privately electronically.

Please answer all the questions completely, but pay special attention to the following sections:

Personal Information
Worker's Compensation or Auto Insurance information (if applicable)
Medical Questionnaire (please complete every line)
Please sign the "Payment Responsibility" section where applicable (1st, 2nd, and 3rd lines apply to all patients.)
HIPPA form (see below.)

HIPAA Forms

Privacy and Your Health Information
Consumer Rights (Your health information privacy rights)

En Espanol:

Privacy and Your Health Information (en Espanol)
Consumer Rights (Your health information privacy rights) (En Espanol)