Patient Forms

New patients: Please print and fill out all the forms below. Be sure to bring the completed forms with you for your office visit.

Consent, Payment Policy and Payment Agreement

Message Authorization and Acknowledgement of Notice of Privacy Practices

New Patient History

Patient Information

Patient Portal Email Authorization

Privacy Practices


If you are a new concussion patient who will be seeing any of our Concussion Clinic physicians, please also print and fill out the Concussion Intake Form below and bring it to your office visit as well.

Concussion Intake Form

 

If you are an EMG patient and will be have a EMG at one of our clinics, please fill out the EMG Intake Form below and bring it to your upcoming office visit.

EMG Intake Form


If you are a follow up concussion patient who will be seeing any of our Concussion Clinic physicians, please fill out the below symptom scale form for your follow up visit.

Follow Up Symptom Scale


If you are a new head pain patient who will be seeing Dr. Lane, please fill out the Head Pain Intake Form below and bring it to your upcoming office visit.

Head Pain Intake Form


If you would like to authorize the use or disclosure of your Protected Health Information (PHI) to a particular person or entity, please use the form below.

Authorization for Use/Disclosure of Protected Health Information

 

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