Patient Forms

Download any of our patient forms below. You will need the Adobe Acrobat Reader to open any form. 

New Patient Forms

General information needed for each new patient… i.e – Name, Address, City, State, etc…

Credit Card on File Policy

This form allows the office to keep a form of payment on file so that any balances unpaid by insurance can be promptly taken care of, eliminating the need for mailed in or phoned in payments.

Medical Records Release

Allows you to give us the legal right to release sensitive Health Information to other health providers…

HIPAA Authorization

This form grants us permission to discuss your medical care and/or leave phone messages regarding your care only (and ONLY) with the people you list. This includes your health information, laboratory results, test results & financial information.

HIPAA – Health Information Portability & Accountability Act

HIPAA Notice of Privacy Practices

This form describes how medical information about you may be used and disclosed and how you can gain access to this information.

Female Health Assessment Questionnaire

This female BioIdentical Hormone Questionnaire gives us both a good indication as to whether or not our RightBalance Hormone replacement therapy might be of help…

Male Health Assessment Questionnaire

This male BioIdentical Hormone Questionnaire gives us both a good indication as to whether or not our RightBalance Hormone replacement therapy might be of help…

Understanding your BMI Testing Results

Understanding your BMI Testing Results gives you a much better indication as to whether or not our RightBalance Hormone replacement therapy might be of help…

Votiva Informed Consent

Votiva Informed Consent form (required)

Votiva Self Assessment

This form helps you determine if this procedure is right for you…

Votiva Patient Instructions

Votiva Patient Instructions

(FormaV / FractoraV)