NEW PATIENT FORMS

You may refuse to fill out this acknowledgement. By filling out these forms, you are verifying that you have received a copy of this office’s Notice of Privacy Practices.

IF YOU ARE UNCOMFORTABLE WITH THE ONLINE INTAKE FORM, PLEASE DON’T HESITATE TO CALL:  719-488-2292.  Marissa, TOMMIE OR SHELLY WILL BE HAPPY TO MAIL, OR EMAIL THE FORMS TO YOU.

I AM THE “PERSONAL REPRESENTATIVE” AND HAVE LEGAL AUTHORITY TO MAKE HEALTH CARE DECISIONS ABOUT THE FOLLOWING PATIENT: