Intake Forms

Downloadable forms allow you to fill-out initial paperwork in the convenience of your own home and at your own pace.

  • Forms will allow you to edit online.
  • Forms do not transmit data.
  • To save your information, save the file to your computer.

Patient Intake Forms



1) Unless prior arrangement is made, full payment is due at the time of service.

Your payment options are: cash, check, or credit cards.

2) Insurance Billing

o If you would like us to bill your insurance, we will contact your insurer(s) and bill them based upon the non-guaranteed information they provide to us.
o You are responsible for all co-payments, deductibles and other adjustments made by your insurer(s).
o If we are unable to obtain a verification of benefits from your insurer for any reason, we will require full payment at the date and time of service.
o Insurance companies may reimburse differently than the information they initially provide to us.
o You are responsible for and will be billed for any resulting unpaid balance.

3) Discounts

We offer the following cash discounts. Only one discount may be applied to a bill.

o “Time of Service Discount”

4) Missed Appointments/Late Cancellations

All appointment cancellations must occur within 24 hours of the appointment. If it is less than 24 hours, you will be charged $75 for the missed appointment.

5) Past Due Accounts

Accounts greater than 30 days past due will be charge a $10 administrative fee. Accounts greater than 90 days overdue will be sent to a collections agency.

These policies are subject to change without notice.