Patient Paperwork

Below is the New Patient Paperwork.

Click on each file below to download it

Note: The HIPAA Privacy Policy is available for your information and does not need signed or returned.

Female-intake-forms_wclinic_ccway_2016

Male-intake-forms_wclinic_ccway_2016

Pediatric-intake-forms_wclinic_ccway_2016

HIPAA Privacy Policy_UpdatedOctober2014

Please Note there is a Required 24 Hour Cancellation Notice for any cancelled appointments. Appointments canceled with less than 24 hours notice or not at all (a no show) will be subject to a late cancel fee.

New Patient Appointments canceled with less than a 24 hour notice or a No show/Missed New Patient Appointment will result in us having to take a credit card number on file in order to reschedule your appointment.

If you are using Health Insurance for your visit (or you have new/different Health Insurance for your visit), please provide us with your insurance information (Insurance Company name, ID, Group #, Plan, and/or copy of insurance card) 24 hours or more prior to your appointment date. This ensures that your insurance is verified ahead of time, allowing for the full scheduled time for your appointment with the doctor. If we do not receive your health insurance information ahead of time, we have the right to reschedule your appointment to a later date.