New Patient Packet
- The new patient packet is normally mailed to each new patient,
once an appointment has been made. Below are the forms that you would
normally receive in the mail.
- If you don't want to wait for the mail, or if you have misplaced one of
the forms mailed to you, you may download them here.
- Remember, all the forms below must be downloaded, printed out, filled
out, and brought with you to the clinic for your first appointment.
- Bring with you a photo ID, current copies of your insurance
cards, and a list of any doctor prescribed medications that your
are currently taking.
PLEASE DO NOT MAIL THESE FORMS BACK TO US, JUST BRING
THEM WITH YOU ON THE DAY OF YOUR APPOINTMENT.
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This form will help you find your way to us.
It contains Both written directions of how to find our clinic, and a
detailed color map showing the way.
JEC SKU# 0001
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We need this form to start your patient file.
This form is for your general information: name,
address, phone, employer, insurance, emergency contact and other basic
information needed for your file.
JEC SKU# 0002
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This form authorizes the release of certain medical
information.
This form is needed to provide continuing care for our
patients, legal reasons and requests for information, for personal use of the
patient, for patient's school, for worker's compensation and other
reasons.
JEC SKU# 0003
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This is a reminder of the date and time of your scheduled appointment with
our office.
This form also gives you information on what to do the day of your
appointment, and what to do in the event you need to re-schedule or cancel your
appointment.
JEC SKU# 0004
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This form is to provide the doctor and medical staff with information related
to your current and past medical history.
This includes, but is not limited to, medications and past medical
conditions.
JEC SKU# 0005
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This is simply a HIPAA information guide provided for your convenience.
It does not require your to fill out anything.
This form details for you our commitment to patient medical record privacy.
JEC SKU# 0006
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This form is needed to insure your understanding of patient financial
obligation for services rendered.
It explains co-payments, patient insurance filing policy, required insurance
doctor referrals and more.
JEC SKU# 0007
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Due to confidentiality laws, it is necessary for us to have written
authorization to share your personal information with any friend or family
member of your choosing, in the event you become incapacitated.
JEC SKU# 0008
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This form is a written record receipt that you have received a copy of our
Notices of Privacy Practices.
JEC SKU# 0009
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