New Patient Intake Form

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my health. It is my responsibility to inform the doctor's office of any changes in my medical status. I certify that I am the patient or legal guardian of hte above listed patient. I authorize this office and it's staff to examine and treat my condition as the medical professionals see fit, including having diagnostic x-ray examination if necessary. 

**This is to ceritify that, to the best of my knowledge, I am not pregnant, and give my permission to have diagnostic x-ray if necessary** (If you are unsure of your pregnancy status, it is very importat that you inform your care provider prior ro any diagnostic imaging.)

This is confidential record of my medical history and pertinent personal information. The doctor/nurse practitioner reserves the right to discuss this information with medical and allied health professionals per this informed consent. Copies of this record can only be released by your written authorization. Copies of this record can only be released by your written authorization.