Fax, mail, or bring in the forms below, and we will call you to schedule an appointment.
Fax: (520) 219 - 3164 / 7366 N. La Cholla Boulevard, Tucson, AZ 85741 There are many free fax apps, such as WeFax, that you can use to fax these forms from your phone or computer.
The doctor must be contracted with your primary and secondary insurance plans in order for you to establish care. We accept many insurance plans, but cannot guarantee their coverage of our services. The patient is responsible for verifying coverage and benefits of their individual policy. It is best to contact your insurance company directly by calling member services (the number is usually listed on the back of your insurance card).
Patient Registration Form
For first-time patients.
patient_registration_form.pdf | |
File Size: | 2189 kb |
File Type: |
Adult Health History Form
We need an accurate and comprehensive medical history so you can receive the best care possible. Adult patients should fill out this form.
adult_health_history_form.pdf | |
File Size: | 175 kb |
File Type: |
Child Health History Form
Please fill out this form for any children who will be patients.
child_health_history_form.pdf | |
File Size: | 2180 kb |
File Type: |
Financial Policy Agreement
Payment of your bill is considered part of your treatment, and a clear understanding of our financial policy is important to our professional relationship.
financial_policy.pdf | |
File Size: | 111 kb |
File Type: |
Patient Privacy Notice
This notice describes how medical information about you may be used and disclosed and how you can get access to this information.
notice_of_privacy_practices_acknowledgement.pdf | |
File Size: | 1090 kb |
File Type: |