Please complete for your first visit to our office. Thank you!


Patient History

Consent For
Release of Info

Consent Form

Billing Questions/ Online Payments

Contact our billing company BillPro Management Systems at 1-800-736-0587 ext: 0217


We request all medications or a list of medications be brought to every office visit in order to ensure patient safety and to avoid any dosing errors that may occur.

If a prescription call in is required please call your pharmacy and have them fax us a request. Please allow at least 48 hours for the pharmacy to receive a response.

Your insurance card must be presented to every appointment in order to be verified to prevent any claim rejection or confusion. If you are on Medicaid and do not have your monthly card you may be asked to reschedule.

If you arrive 15 minutes late you may be asked to reschedule.

There is a $25 fee for all no show appointments. After three missed appointments it may result in a dismissal from the practice.

All copays are due at the time of visit, if not collected there is a $5 processing fee.

All NSF checks returned will be required to pay a $25 collection fee.