Unfortunately, we can’t start our work together without you first filling out a few forms. Please print out and complete the forms below, signing them where necessary and bring them with you to your appointment. Completing this paperwork ahead of time will enable us to quickly turn out attention to solving your problem.
General Health Screen:
This form enables the recognition and screening of potential diseases and disorders.
Intake Demographics and Consent to Treat:
This form collects demographic information, provides consent for your treatment, and informs you of my practice policies.
Notice of Information Practices
This notice describes how information about you may be used and disclosed and how you can gain access to this information. Please review it carefully.
Medical Insurance Reimbursement
An Insurance Reimbursement form is available should you decide to use it.
Policies and Pricing
This notice outline's Dr. Pirtle's policies on scheduling appointments, pricing, cancellations and refunds. Please review it carefully.
General Health Screen:
This form enables the recognition and screening of potential diseases and disorders.
Intake Demographics and Consent to Treat:
This form collects demographic information, provides consent for your treatment, and informs you of my practice policies.
Notice of Information Practices
This notice describes how information about you may be used and disclosed and how you can gain access to this information. Please review it carefully.
Medical Insurance Reimbursement
An Insurance Reimbursement form is available should you decide to use it.
Policies and Pricing
This notice outline's Dr. Pirtle's policies on scheduling appointments, pricing, cancellations and refunds. Please review it carefully.
