Please review and fill out these forms then click “submit”. A prompt will let you know that the forms have been submitted properly. We look forward to seeing you!
It is important to “submit” the forms instead of printing them yourself. If you print them and bring them in, it may result in having to to re-do the forms. These forms are a legal requirement in order to be seen as a patient at this practice. All patients must complete the required intake forms prior to their preliminary evaluation.
- Patient Info Form
- PCP Release (Primary Care Physician Release)
- General Release (For anyone other than your Primary Care Physician)
- Pharmacy Intake (Medical Only)
- Intake Questionnaire
- Financial Agreement and Worker’s Compensation/No Fault
- PHQ-9 Form
- Privacy Notice and Confidentiality Agreement
- Consent for Treatment (Required by law to complete to see any practitioner at this practice)
- Intake Questionnaire (For New Patients of Kenna Burns ONLY)
- Telemedicine Consent Form
- Photo ID Card and Insurance Card Submission