Forms

By submitting your completed forms via email , you are acknowledging that you are sending protected health information via non-encrypted email and there is a risk that your health information could be compromised.

New Patient Packet

Please complete these online forms:  https://intakeq.com/new/GhLASl

After your complete all five forms, your information will be sent to us and then you may call the office to schedule your first appointment.

OR

If you prefer to complete this packet on paper, please print the packet form linked below, fill it out and then bring it with you at your next visit.
New Patient Packet

Patient Release Form

The Medical Records Release Form is required for patients who are leaving our practice and need their records transferred to another practice. Please download this form and fill it out completely with parent’s signature and mail or fax to our office.
Medical Records Release Form