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Forms

Notice of Privacy Practices

Receipt of Notice of Privacy Practices
Please complete prior to your first visit (revised 12/21/16)

Registration Form
Please complete prior ro your first visit (revised 12/21/2016)

Transfer of Medical Records
Please complete if you are leaving the practice/requesting records to be sent to another provider

Record Release for New Patients
Please complete if you are new patient transferring care into our practice

Record Release
Please complete if you are requesting records to be sent to our practice from other provider/specialist

18 Year and Older Consent

Lead Risk Questionnaire

eEHX Information

eEHX Opt Out Form