Forms

New Patient Forms

Please do not complete these forms until after you’ve been offered an appointment date and time.

Please create a Patient Portal account and complete and submit New Patient Registration forms at least three business days prior to your first appointment unless otherwise requested. If you do not, your appointment will be rescheduled to a later date. Please call the office if you are in need of assistance.

ADULT NEW PATIENT REGISTRATION FORMS

CLICK HERE TO BE TAKEN TO THE PATIENT PORTAL PAGE

Three business days cheat sheet:

If your appointment is scheduled for a Monday, forms must be received by 5 PM on Wednesday of the previous week.

If your appointment is scheduled for a Tuesday, forms must be received by 5 PM on Thursday of the previous week.

If your appointment is scheduled for a Wednesday, forms must be received by 5 PM on Friday of the same week.

If your appointment is scheduled for a Thursday, forms must be received by 5 PM on Monday of the same week.

If your appointment is scheduled for a Friday, forms must be received by 5 PM on Tuesday of the same week.

Records Release Form

To request that your records be sent to you or another party, fully complete and submit this form. Once the completed form has been received and it is determined that the requested information exists and can be released, the requested information will be provided within fifteen days.

Please note, if you submit a form on a day the office is closed, the date of receipt of that form will NOT be the day it was sent by you, it will be the day it was actually opened and viewed by Dr. Emick or a member of her staff. For example, if you submit the form at 11:30 PM on a national holiday, the actual date of receipt will be the first business day the office is open. 

AUTHORIZATION TO RELEASE/EXCHANGE INFORMATION FORM