New Patient Form
If you are uncomfortable with the online intake form, please don't hesitate to call: 719-488-2292. Tommie or Shelly will be happy to mail, or email the forms to you.n
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:
New Patient Form
If you are uncomfortable with the online intake form, please don’t hesitate to call: 719-488-2292. Tommie or Shelly will be happy to mail, or email the forms to you.n