Patient Forms

Online Patient Registration

You may preregister with our office by filling out our secure online Patient Registration Form. When entering your information, please press the TAB key to go to the next field and NOT the ENTER key.  If you do press the enter key before you have completed the form, you may complete another form online or complete the form once you arrive at the office.  After you have completed the online form, please make sure to press the Submit button at the bottom to automatically send us your information.  

Financial and Privacy Practice Forms

Please review our Notice of Privacy Practices which is available below.  After reviewing the document,  print off  the Acknowledgment of Receipt of Notice of Privacy Practices ,  Statement of Financial Responsibility and the Insurance/Network Participation List .  Sign each of the documents and bring them with you to your appointment.

• Notice of Privacy Practices (summary)
• Notice of Privacy Practices (complete)

Prescriptions

For your convenience we are able to dispense most prescription medications in our office, saving you a wait at the pharmacy. Please print our Prescriptions Form and read for further details.  Please bring the completed form with you to your appointment.

Financial Assistance

Financing is available for 90 days with no interest.  If you would like to utilize this option for your payment, please apply at American General Finance  (Indiana residents only).  In order to apply online, you must have a valid email address.  You will be notified by American General regarding the status of your application.  Our office will only be notified if your application is approved. 

 Please Note:  some of our forms may require Adobe Acrobat reader. You may download the free plugin for Adobe Acrobat to view these forms.   If you choose not to download the plugin, please arrive 15 minutes prior to your appointment to complete your registration.