New Patient Information and Patient Forms

Appointment Checklist

  • Please bring in a copy of the patients insurance card and the drivers license of the primary cardholder.
  • Legal Guardians should bring proof of guardianship.
  • If someone other than the parent or legal guardian brings in a child under the age of 18, they should have a written note of consent to provide care for that child.
  • A patient who is new to our practice should arrive 15 minutes prior to their appointment time to complete paperwork. You may also print the paperwork from this site and bring it with you to the appointment.

Read the HIPAA Policy pdficon_small

Forms for New Patients --
Form Bundle pdficon_small Contains

  • Registration Data and Insurance Information Form
  • Billing Department Form
  • HMO Patient Form
  • Waiver of Liability Commercial Insurance Plans Form
  • Disclosure of Protected Health Information Form
  • HIPAA Policy for Review
  • Record Release Form for New Patients

Only for Newborns -- Record Release Form for Newborns pdficon_small

Health Forms

Other Forms

42141 Mound Road  -  Sterling Heights, MI 48314  -  phone: 586-254-7593  -  fax: 586-254-7834