I have completed this form to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status.
So that we may assure you and other patients of uninterrupted treatment it is necessary for all patients to accept a definite arrangement for the appointments. Once an appointment is made, please remember this time is reserved for you.
Thank you for filling out this form completely. It will enable us to help you more effectively. If you have any questions at any time, please ask us. We are happy to help.