PAPERWORK

FIRST APPOINTMENT

IF YOUR ARE PREPARING FOR YOUR FIRST APPOINTMENT WITH US, PLEASE COMPLETE THE NEW CLIENT PAPERWORK AND BRING IT WITH YOU TO YOUR FIRST APPOINTMENT ALONG WITH YOUR INSURANCE CARD AND PHOTO ID.

COVID19 IN-PERSON CONSENT FORM

IF YOU ARE COMING IN FOR AN IN-PERSON SESSION, YOU WILL BE REQUIRED TO COMPLETE THE COVID19 IN OFFICE CONSENT FORM

RELEASE OF INFORMATION

IF YOU ARE A CURRENT CLIENT AND WOULD LIKE YOUR RECORDS SENT TO OR OBTAINED FROM ANOTHER FACILITY OR PROVIDER, PLEASE FILL OUT THE RELEASE OF INFORMATION FORM BELOW AND RETURN IT TO OUR OFFICE.

PAYMENT AGREEMENT

IF YOU CURRENTLY HAVE AN OUTSTANDING BALANCE WITH US AND WOULD LIKE TO SET UP A PAYMENT PLAN. PLEASE COMPLETE THE FOLLOWING AGREEMENT AND RETURN IT TO OUR OFFICE.

1910 ST. JOE CENTER RD. SUITE 23 FORT WAYNE IN 46825

PHONE: 260-484-5599

FAX: 260-484-5664

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