| Patient Downloads |
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You will need to have Adobe Reader installed on your PC to view these forms. It is a free download from Adobe. |
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Checklist
This provides a list of things for you to bring to your first appointment.
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New Patient Information
Please fill this out as completely as possible. We submit prescriptions electronically, so make sure you have the information of the pharmacy you use, including fax number (you can call them to ask for it if it is not on your prescriptions). Once completed, bring this to your first appointment.
You may also elect to fax it to us at
(502) 425-6629.
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Policies and Procedures and
Notice of Privacy Practices
The "Notice of Privacy Practices" describes how we are required to use your information. The "Policies and Procedures" explains more about our office policies. You do not need to print out these unless you desire to do so; just make sure you read and understand them. You will sign acknowledgment of receipt of these at the time of appointment.
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Authorization for Disclosure of
Protected Health Information
This is needed if you want us to share your information with your primary care physician, therapist and/or anyone else. You only need to print this and fill it out if you want us to share information. If so, make sure to fill in their name/contact info on #3 of this document. If other providers have information that you feel would be important for us to have, please have them fax such records to (502) 429-6629 (examples included hospitalization records, psychological testing results, therapy notes, previous treatment records, etc.) prior to your appointment. |
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Signature Page
Please read and sign this “Signature Page” and bring to your first appointment. This acknowledges that you have read and understand our “Policies and Procedures” and our “Privacy Policy." |
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Driving Directions
GPS/online maps may lead you to an inaccurate location, so please download our PDF map. |
