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Patient Forms – New Patients (or if you haven’t been seen by us in 3 or more years)

During your first visit we want to know all about you. If you have had any tests, x-rays or other information be sure to bring them with you. Please fill out the Comprehensive Patient Questionnaire and Patient Registration Form, then print and bring to your appointment.

Patient Forms – Established Patients (with demographic changes and/or if you haven’t been seen by us within the last year)

If any patient information has changed since your last visit (i.e. insurance carrier, address, etc.) please update us by completing a new patient registration form and print and bring to your next appointment. If you haven’t been seen by us within the last year please also complete the Patient Questionnaire Update form.

Disability Forms

There is a $25 charge for each Disability or Family Medical Leave Act (FMLA) form we complete on your behalf. These forms may be required by an employer, home or auto loan or any other facility that requires disability information. Allow up to five business days to process your request. Please complete and return to the office the Release of Information form below which will be necessary to complete your request.
Dr.Chafik with patient
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