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Concord Location: (978) 369-2525 | Lexington Location: (781) 861-8855

Registration Forms

Registration Page

The forms below are those which would be given to you at our office prior to your being seen for your appointment. The first two are for our information so that we can best treat you and the last two are are required by law. You may find it easier to download, print and fill out these forms prior to your appointment.

Patient Registration – Please provide us with all of your address and insurance information. It is important the form be completed in its entirety in order for us to have accurate information to bill you insurance. Please also bring your insurance cards to your appointment as we need photocopies of them for our records.

Health History – On this form you will need to fill in your entire medical history as it pertains to your health today. All information is important and please remember to list ALL medications you are currently taking. If this list is extensive please feel free to bring a separate list and we will be happy to copy it for you.

Billing Policy and Privacy Acknowledgement – This form goes over our office policy on billing and insurance and gives us permission to bill your insurance on your behalf. This form also lists all of the insurance companies that we are in network with.

Privacy Policy Acknowledgement – This form is for Acknoledgrment of Reciept of Notice of Privacy Policies

Privacy Policy– This form is required by law and states only that we offered you a copy of our privacy policy.

801 Main Street, Suite 4
Concord, MA 01742
(978) 369-2525
35 Bedford Street, Suite 18B
Lexington , MA (978) 369-252502420
(781) 861-8855