New Patient Packet Form

Welcome to our New Patient Packet page!

We're delighted that you've chosen us for your healthcare needs, and we're excited to get to know you better.
We know that filling out forms isn't always the most enjoyable task, but rest assured that this one will help us provide you with the best possible care. We're here to support you every step of the way, so don't hesitate to reach out if you have any questions or concerns.

Please take a moment to fill out the necessary fields. Fields marked with an asterisk (*) must be filled out.
As you progress through each section, click "next" to move forward and complete the entire packet.
When you're finished, click "submit" to send us your information and take the first step toward better health and receiving your top-quality care you deserve. Thank you for choosing us as your healthcare provider, and we look forward to building a long-lasting relationship with you!

Social Security Number

⠀

Wish not to disclose

Employer (If Applicable)

Emergency Contact Name

Primary Care Physician

Office Location or Phone Number

Do you have an Advance Directive?

Yes No

Please tell us what do you have

Do you give consent for CVC have permission to view your prescription history from external sources?

Yes No

Can we share your prescription information with other medical providers?

Yes No

Can we release medical record information to the insurance company to process the claim?

Yes No

Can we release medical records information to providers listed in your chart?

Yes No

Can we Electronically Send and Receive Medical Records through Integrated Data Exchange?

Yes No

Please specify the language

Insurance Information

RESPONSIBLE PARTY OR PRIMARY INSURANCE SUBSCRIBER

Relationship to Patient

If Not Self (Otherwise leave blank)

Social Security Number

Insurance Information

Primary Insurance Company Name

Secondary Insurance Company Name

Notice of Privacy and Authorization Form

If a copy of my personal information is needed for reasons other than immediate treatment, I hereby authorize the release of information to the following: family members, Providers, or friends, acting on my behalf.

Please choose one of the options below

I understand that I may amend this authorization at any time, until then this form will be kept on file until further changes are made. I also understand that any other request for personal health information by anyone other than those listed will require additional authorization by me in writing. I refuse to have any information be released to anyone, this includes: Family members, Providers, or friends, acting on my behalf.

Patient or Legal Representative Signature

The Legal Part...

Thank you for completing our patient packet form. We understand that the legal documents are not the most exciting part, but we're just a couple of signatures away from completing your registration.

To complete your registration, please download the legal documents by clicking on the button below. You can sign the documents using multiple methods:

Print the document, sign it, take a picture of it, and upload the picture here.

Use a program like Adobe Reader to sign the document electronically. To do this, open the document in Adobe Reader, click on 'Fill & Sign,' and follow the instructions to add your signature.

If you need any help with filling out the documents, you can find our contact information on the bottom of this page.

If you prefer, you can also come to the clinic to pick up a physical copy of the documents and sign them in person. However, this may delay your registration.

Thank you for choosing our clinic, and we look forward to seeing you soon!

Upload Signed Documents

I submitted the documents or I will fill them out in person

Please ask us how to get to chat with us through the patient portal