New Patient Intake Forms
Please download and complete these forms prior to your first appointment with our office. You may mail them to our MAIL ONLY address at 448 Ignacio Blvd, #294, Novato CA 94949 (this is not our office address), or you may fax them to us at 866.484.0518. Please be sure to provide a copy of your insurance card (front and back) with your forms. Email is NOT a secure form of communication and as such we cannot assure you the private health information contained in the forms will remain private. As such we do not encourage you to use email to send in your forms.
PLEASE NOTE* New patient appointments are only confirmed upon receipt of your new patient intake paperwork. Paperwork must be completed and received by our office 1 week prior to your appointment or you will be requested to reschedule your appointment.
You may also sign up for a Health Gorilla account online to share with our office
Records Request Form
Please use this form if you wish to receive a copy of your medical chart, or a limited part of your medical chart. You may use this form to allow us to send records to your other care providers, to yourself, or to another designated 3rd party. Please note that for paper copies of records we charge $.25/page plus a $15 processing fee and shipping if they are mailed (no shipping charge if they are picked up). You may also elect to receive them on a USB, and will be charged $15 for the USB plus the cost of shipping (no shipping charge if they are picked up). Due to the private nature of the information contained in your medical files, all records that are mailed are done so with Recipient Signature Required. This means the person they are released to will be the person who must sign for the package. At this time there is no fee for faxing your records to you or a third party.
This form must be returned as a hard copy original to our office. You may mail it to our Mail Only address at 448 Ignacio Blvd, #294, Novato CA 94949, or dropped off at our office either in-person, through messenger service or other means.
Fax=Free, Share via Health Gorilla (free), Paper Copies $.25/page + $15 processing fee + shipping, USB $15 + Shipping
Medical Release Form (Non-Provider)
Please download and return this form to our office if you wish to authorize another individual (non-provider) to have access to your records. Due to the nature of the release we require these forms be completed, signed and a hard copy provided to us. You may have it dropped at our office or if you wish to mail it to us please mail to 448 Ignacio Blvd, #294, Novato CA 94949 (Mail-Only address).
Medical Release Form - Provider
Please download, complete and return this form to us if you wish to release records to another care provider or medical professional. Due to the nature of the release we require a hard copy original to be provided to us. You may do this via mail, or other form of returning it to our office such as messenger, or dropping it off. If you choose to do so by mail please mail to our Mail Only address: 448 Ignacio Blvd, #294, Novato CA 94949.
Fax=Free, Share via Health Gorilla (free), Paper Copies $.25/page + $15 processing fee + shipping, USB $15 + Shipping