Become a Patient: How to Register

You can download and print these forms then mail them or scan and email them to [email protected]. If you prefer you can register online in the form shown here, then upload any documents as discussed below.

If you have insurance, we will need a copy of your current insurance card. We will ask for the regular market price for services, or the co-pay required by your insurance company, unless we have received specific information about your residency and finances.

If you’d like to apply for our sliding scale fees, here are the items we will need to complete your registration:

Residency
Two pieces of mail with your current street address and a recent postmark OR
A copy of your lease or mortgage

Income
Documentation that includes all of your own income and that of your spouse, such as:

  • One-month of pay stubs
  • Recent benefit letters regarding social security, pensions or unemployment
  • Court order regarding child support
  • SNAP benefits (food stamps)
  • 1040 federal income tax return form
  • Self employment documentation such as Schedule C of your IRS 1040 form
  • Letter of Support (From the person who is paying for your food and shelter to verify that you don’t have your own income.)

Please call our Clinic if you have any questions about these forms or other documents.

*All of these forms are required to complete your registration!*

Patient Information Patient Partnership Agreement Health History Consent For Treatment

Print The Forms

Each form must be printed and filled out. You may scan the filled form and email it to us, or drop it off at our physical location.

Patient Information Patient Partnership Agreement Health History Consent For Treatment