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

Download and complete both forms.

Be sure to also download and complete the Insurance Pre-Verification Form below if you will be using health insurance to pay for your care.

Adult

Returning Patient

Welcome Back to WellSpring!

Download and complete both forms.

Be sure to also download and complete the Insurance Pre-Verification Form below if you will be using health insurance to pay for your care.

Pediatric (until age 12)

New Patient

Download and complete both forms.

Be sure to also download and complete the Insurance Pre-Verification Form below if you will be using health insurance to pay for your care.

Pediatric (until age 12)

Returning Patient

Welcome Back to WellSpring!

Download and complete both forms.

Be sure to also download and complete the Insurance Pre-Verification Form below if you will be using health insurance to pay for your care.

Motor Vehicle Accident / Workers Compensation Claim

New Patient

Insurance Pre-Verification Form

Adult & Pediatric

Important: complete this form if you will be using health insurance for your care.

Motor Vehicle Accident / Workers Compensation claims do not need to complete this form.

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