About You

Identity and Contact Information

We need to know your full name, birth date, Social Security Number, address, and telephone contact information in order to start a new chart for you in our office. We would also like to know who to contact in case of an emergency and whether or not you’d like to sign up for our Patient Web Portal.

• Click here to print and fill out our Patient Info form.

Your Personal Health History

In addition, we’ll need to know a lot about your Health History, including the medical problems you’ve had, medications you’re taking, allergies and immunizations, specialists who’ve been involved in your care, hospitalizations and surgery or injuries, symptoms you may have, and something about your background and family history. Filling out this information might take some research on your part but will be very helpful to us in providing the kind of quality care you deserve.

• Click here to print and fill out our Health History form.

Your Medical Records

Before we see you for your first visit, it would be very helpful to have copies of medical records from other doctors, clinics, or hospitals that have treated you in recent years. Please use the link below to print individual Release Forms that you can fill out and send to every place that might have helpful information about tests and treatment that you’ve received.

• Click here to print Release Forms so you can send for copies of your old medical records.