Forms & Policies

Save yourself some time at your visit by downloading and completing the following office forms. Note that all forms are in PDF format and require Acrobat Reader to open, view and print them. If you do not have the application, click here to download it to your computer.

Patient Registration Forms PAGE 1 | PAGE 2

Medical History Form PAGE 1

Acknowledgement of Receipt of Notice PAGE 1

Office Policies All patients need to bring insurance cards, and we recommend you call your insurance and be sure of your coverage before scheduling an appointment. Self-Pay: If you do not have insurance we ask for payment at the time of service, unless arrangements are made prior to your appointment with the billing department Co-Pays: Co-payments are due at the time of your visit. We accept cash, checks, and Visa/Mastercard. Bounced Checks: There will be a $15.00 administrative fee, in addition to all bank charges, for all returned checks. We reserve the right to refuse payment by personal check. Late for Visits: We strive to see you at the time of your scheduled appointment. We require you to be on time for your visits. If you are 10 minutes or more late, we reserve the right to reschedule your appointment. Failed Visits: Please call as soon as possible if you are unable to keep an appointment. We require 24-hours notice (or one business day) if you cannot make your appointment, or we reserve the right to charge a $75.00 broken appointment fee. Appointment Scheduling: We DO NOT ACCEPT WALK-INS. Please call to schedule a time to see the doctor. Changes: Please notify us as soon as possible with any change of your information or insurance. Office Visits: Please bring a list of all medications you are taking with you and notitfy us of ANY changes in health/conditions. Cell phone use and smoking are prohibited while in the office.

Call us at 860-537-3521. Nancy will help you make your initial appointment. Your time is important! We make every effort to accommodate your schedule and see you at your scheduled time.