Forms

Click Here for telemedicine visits

Patient Paperwork

New Patient Paperwork

Chronic Care Consent Form

New Patient paperwork can be filled out and signed digitally:

Click the button below and follow the simple instructions to fill out your new patient packet

Click here for digital new patient packet

Chronic Care Consent Form

This consent form is for patients that are eligible to receive chronic care management

Click here for Chronic Care Consent

Telemedicine Consent Form

Chronic Care Consent Form

Telemedicine Consent Form

This consent form is for patients that are using our Telemedicine Services for remote medical care

Click here for Telemedicine Consent Form

Telemedicine Consent Form

Chronic Pain Management Contract

Telemedicine Consent Form

This consent form is for patients that are using our Telemedicine Services

Click here for Telemedicine Consent Form

Chronic Pain Management Contract

This outlines our chronic pain management policy and must be completed yearly

Click here for Pain Management Contract

Release of Records Request Form

Chronic Pain Management Contract

This form is used to request your private health records from your previous provider or from recent hospital visits

Click here for Release of Records form

Buprenorphine (Suboxone/Subutex) Consent Form

PREGNANT PATIENT Office Based Addiction Therapy

Buprenorphine (Suboxone/Subutex) Consent Form

This form outlines our policy for patients who are taking buprenorphine

Click here for Buprenorphine consent form

Depression Screening Brief Survey

PREGNANT PATIENT Office Based Addiction Therapy

Buprenorphine (Suboxone/Subutex) Consent Form

This is a tool that is used by patients and interpreted by your provider in order to screen for depression

Click here for Depression Screening tool

PREGNANT PATIENT Office Based Addiction Therapy

This is a Consent Form for Office Based Addiction Therapy (OBAT) if you are Pregnant.

Click here for OBAT in PREGNANCY CONSENT FORM

DAST Screening Test

Mental Health Intake

PREGNANT PATIENT Office Based Addiction Therapy

This is a Form to Complete for your DAST Screening Test if your Provider requests it.

Click here to complete your DAST Screening Test

Mental Health Intake

This is a Form to Complete for your MENTAL HEALTH INTAKE.

Click here to complete your Mental Health Intake

CASE MANAGEMENT

Mental Health Intake

This is a Form to Consent for Case Management.

Click here to complete your Case Management Consent

Patient Paperwork ADDITIONAL

CONSENT FOR DMPA BIRTH CONTROL

Testosterone Replacement Therapy Consent Form

CONSENT FOR BIRTH CONTROL INJECTION Medication: DEPOT MEDROXYPROGESTERONE ACETATE (DMPA)

Click here for digital DMPA Consent Form

Testosterone Replacement Therapy Consent Form

CONSENT FOR TESTOSTERONE REPLACEMENT THERAPY - Injection or Topical Medication

Click here for Digital Testosterone Replacement Therapy Consent Form

MORE FORMS SOON

Testosterone Replacement Therapy Consent Form