Concierge Medical House Calls . 212-252-2305
Forms for New Patients
All forms for new patients are contained in this document. Clicking on this link, or the one below, will allow you to download the forms to your computer so you can print them out.
Completed forms can be returned by mail, fax, or email. Let me know if you need help with the forms & I will be happy to assist you.
Included in the packet are:
- Patient Information Form (2 pages)
- Health History Form (5 pages)
- Private Contract for Medicare Beneficiaries (1 page)*
- Notice of Privacy Practices (5 pages)*
- Fee Schedule & Payment Agreement (1 page)*
- Release of Information Form (1 page, for your other/previous clinicians, so I may obtain your medical history)
*signature required at or prior to first visit
Questions about the forms? Feel free to call me and I'll give you a hand. Or use the Contact Form to send me an email. I'll get back to you right away.
Once completed, the forms will become part of your medical record in the office. All information will be kept strictly confidential.