Pre-Registration Form (English) for Scheduled Appointment

For UPCOMING APPOINTMENT – Please complete this form prior to appointment.

Please have your Medication List , your pharmacy name and phone number and the phone numbers of anyone you want to have access to your information with you before starting this form.

This information is different than the text you may have received to scan your ID and Insurance Card into our portal.

1. You will be completing 3 forms: Your Medical History, your HIPAA (who can we talk to about your records), and your Patient Financial Policy.
2. Questions with an asterick must be completed.
3. There is one signature required on page 3. You can simply type your name in this space.
4. After you have completed all pages and clicked the SUBMIT BUTTON at the very bottom of page 3, please wait to see a pop up that says “Thank you. Your form has been submitted”. 
5. If the form opens back up to a question or you see any red highlighted areas this indicates that you missed an area that was required. Find and complete any highlighted areas and then re-click the SUBMIT button at the very bottom.
6. You will receive a message that thanks you for your registration when the submission is complete.
7. The form does not save your work. It will time out if you leave the page OR take too long to complete the forms in one session. If you prefer, you can print the forms from our forms list to fill out by hand (HIPAA, Patient Financial and Medical History) and bring them with you for your appointment.
8. Please remember to bring your insurance card and identification when you come for your appointment even though you may have submitted them through our portal.
9. We appreciate your cooperation with this online registration and look forward to seeing you!