New Patient Information and Forms

1st
Both the HIPAA Form and the Service Agreement should be read prior to signing the Consent Form, below.

Required Forms

Optional Forms


 

  1. Forms in PDF Form
    blueclip Both the HIPAA Form and the Service Agreement should be read prior to signing the Consent Form, below. HIPAA FormService Agreement
    blueclip 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)
    blueclip This form can be used to authorize charging your fees to a credit card or bank account. Authorization Form (PDF)
    blueclip This form can be used to authorize the exchange of emails and/or text messages with your provider. Email/Text
    Agreement Form
     (Optional)
    blueclip  This form authorizes GLPG to release specific information to individuals or organizations. Release of Information Form (Optional)