Intake Form

Printable Form:    Web Intake Form (pdf)

If you are a new patient we ask that you fill out an intake form.  This form is for all patients aged 6 years and older.  Thank you in advance!

IMPORTANT: Please read the information below before you press ‘Submit’

After you submit your form, a confirmation message will appear at the top of the screen that reads, “SUCCESS! We have received your intake form. Thank you.” A confirmation email will also be sent to you, which contains all the information you input into the form.  If you do not receive these confirmations, it means that your submission was not processed and will need to be entered again.