Patient Forms

New Patients

The following New Patient forms can be downloaded prior to your appointment. Please fill out the forms completely and answer all questions to the best of your ability. Please bring these forms with you to your first appointment.

• Patient Intake Form (Adult)
• Pediatric Intake Form (Child)
• Confidential Patient Information Form
• Notice of Privacy Practices
• Acknowledgement of Receipt of Notice of Privacy Practices
• Patient Payment and Appointment Cancellation Policy
• Consent Treatment Form

Homeopathy

You may need to fill out additional paperwork if you are coming in for Homeopathy,  Environmental Medicine issues, or Acupuncture. Please see information below.
If you are a new patient coming in for a Homeopathy (Dr. Udell or Dr. S. Messer) or Environmental Medicine (Dr. Crinnion or Dr. Tran) evaluation, you will also need to download these forms and fill them out prior to your first visit. Please answer all questions to the best of your ability and bring them with you to your first appointment.

• Environmental Toxic Exposure
• Homeopathic Intake Form

Acupuncture

If you are a new patient coming in for Acupuncture please fill out the following form in addition to the New Patient forms and bring it with you to your first appointment.

• Consent Form for Acupuncture Treatment

Medical Release Forms

If you would like a copy of your medical records you can complete this form.

• Medical Records Release Form

Discount Program

You must fill out the sliding scale form below to qualify for our discount program.

• Sliding Scale Contract

For any other commnets or concerns contact Patient Services at 480-970-0000.