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New Patient Intake Form

Now you can electronically fill and sign the patient intake form below. In compliance with HIPAA requirements, your information is always kept private and secure.

Having trouble?

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Can’t edit or move typer? Click here to open this form in a separate window.

Still not working? Contact us for help.


Please use a laptop or desktop computer!


  1. Fill out the fields and sign where indicated.
  2. When finished, click the big orange “DONE” button at the top of the document window.
  3. Click “Yes” in the popup box to confirm your submission.
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It looks like you are using a device with a small screen. For your convenience, please use a desktop or laptop computer to fill out your form. If you are having trouble filling out this form on your device, try using this dedicated link with an app for mobile devices.

Trouble filling out the form? We're here to help!

Our Office Manager Ana, is ready to break the ice!
Ana, Office Manager

Try using this version if you are experiencing difficulties. You can also call or get in touch with us at if you need help filling out this form.

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