Both the HIPAA Form and the Service Agreement should be read prior to signing the Consent Form, below.

HIPAA Form

Service Agreement

The PDF version of this form can be printed, signed, and brought to your first appointment.

OR

The electronic version may be filled out and submitted online.

Consent Form (PDF)

Electronic Consent Form

This form can be used to authorize charging your fees to a credit card or bank account.

Payment Authorization Form

This form authorizes GLPG to release specific information to individuals or organizations.

Release of Information Form (Optional)