Intake Form
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HIPAA Form

We have given the above named patient a copy of our Notice of Privacy Practices. We have answered any questions that they have regarding this form.
Please list any any individuals that you would like to have access to your medical records.

Your Signature (HIPAA)

Permanent Signature Authorization

Your Signature (Permanent Signature Authorization)

To Schedule An Appointment

Call 631.923.1420​