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

New Patient Forms

Please create a Patient Portal account and complete and submit New Patient Registration forms at least twenty-four hours prior to your first appointment. If you do not, your appointment will be rescheduled to a later date. Instructions are available in the New Patient Manual below. Please call the office if you are in need of assistance.

ADULT NEW PATIENT REGISTRATION FORMS

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