Forms for New Patients & Returning Patients

Please download and fill out the appropriate form below. You can either fax or mail it to us before your first appointment, or bring it when you come. For your privacy and security, please do not email completed forms to us.

Don’t hesitate to contact us if you have any questions.

NOTE: There’s a difference between New Patient forms and New Patient Motor Vehicle Accidents/Workers Compensation claim forms. Be sure to choose the correct one.

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Adult

New Patient

New Patient

Welcome Back to WellSpring!

Pediatric (until Age 12)

New Patient

Returning Patient

Welcome Back to WellSpring!

Motor Vehicle Accident / Workers Compensation Claim

New Injury-Relared Case

Additional Forms

Medical Records Transfer
Releasing WellSpring Records

Medical Records Transfer
Requesting Records from Other Practitioners

Notice of Patient Privacy Practices (HIPPA long form)

Cancer Diagnosis and Treatment

Health Review and Medical Update

Additional Forms

Medical Records Transfer
Releasing WellSpring Records

Medical Records Transfer
Requesting Records from Other Practitioners

Notice of Patient Privacy Practices
(HIPPA long form)

Cancer Diagnosis and Treatment

Health Review and Medical Update