Forms

Notice of Privacy Practices EOPA
Notice of Privacy Practices.pdf. This notice describes how medical information about you may be used, disclosed and safeguarded, and how you can get access to this information. Please review it carefully, then print the signature page (page 6) and bring with you.

Financial Agreement and Privacy Practices
Financial Agreement and Privacy Practices.pdf. This form is to ensure that you are fully aware and responsible of payment for treatment that may or may not be covered by insurance.

History Form
History Form.pdf. This form helps us evaluate your needs. It is a brief history of your health and your family background.

Release of Information
Release Of Information.pdf Please fill out this form if you would like to allow another person or organization to receive information about you.