Forms

Online Forms-Columbia City

Welcome Form Please "click" on link below to enter general patient information and insurance details. When completed, please return to fill out the Medical Information form as well. Thank You!
CLICK HERE FOR FORM
Medical Information Form Please "click" on link below to be connected to enter Patient Medical Information. Thank You!
CLICK HERE FOR FORM

Online Forms-Roanoke

Welcome Form Please "click" on link below to enter general patient information and insurance details. When completed, please return to fill out the Medical Information form as well. Thank You!
CLICK HERE FOR FORM
Medical Information Form Please "click" on link below to be connected to enter Patient Medical Information. Thank You!
CLICK HERE FOR FORM

Printable Forms

For your convenience, we have provided our required forms so that you can complete them in the comfort of your home. This allows you to fill out the necessary information without feeling rushed, and shortens your initial appointment. Simply print out the following forms, complete and bring them to your first visit.

 

Please Note: Your appointment is time reserved for you and only you. Missed appointments without at least 24 hour notice will be subject to a charge.

 

Why A Charge: A schedule that has consistent "no-shows" drives up prices for everyone by creating an inefficient practice. We do not want to punish those who show up for their appointment with higher fees, nor do we want to punish staff by having them clock out when their patient does not show for their appointment. Thus, it only seems fair that the burden be placed on the individual responsible for the situation. We of course make exceptions for emergencies.

 

Thank you for your understanding in this matter.

 

HIPAA Privacy Form (26K)

 

Notice of Privacy Practices (325K)

 

Office Policy (188K)

 

Patient Info & Dental Insurance (103K)

 

Patient Medical Information (90K)