Patient Forms
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Patient Registration Forms
- Patient Medical History Form
- Patient Questionnaire
- Patient Registration
- Pain / Numbness Diagram - SPINE PATIENTS
- Privacy Policy
- Acknowledgment of Receipt of Notice of Privacy Practices
- HIPAA Patient Consent for Use & Disclosure of PHI
- Authorization to Disclose Health Information
- Agreement for Controlled Substance Prescription
- Cautions Regarding the Use of Long Term Narcotics
- Financial Statement Policy
- Neck Index (use if you are being seen for neck/arm pain)
- Back Index (use if you are being seen for back/leg pain)
CONTROLLED SUBSTANCE POLICY (STATEMENT)
Controlled substance medications (i.e. narcotics, tranquilizers, and barbiturates) are very useful, but they have high potential for misuse and are therefore closely controlled by the local state and federal government. If you are prescribed a controlled substance, we ask that you agree to our controlled substance protocol. If you will not accept our protocol, we cannot treat you and you will need to work with another physician.
Agreement for Controlled Substance Prescription
Cautions Regarding the Use of Long Term Narcotics
Financial Statement Policy
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Medical Records Release Authorization
- Medical Record Authorization Form
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