Patient Resources – Patient Forms

The following forms are provided for you ahead of your visit. You are welcome to fill out these forms at home. You may then e-mail the forms back to us prior to your appointment or print out the forms and bring them in with you. Please fill out the Patient Intake Form in its entirety as it will provide us with all the necessary medical information Dr. Tansavatdi needs for your evaluation with her.

We look forward to meeting with you!
 
Patient Intake Form

In order to access this file please make sure you have the most recent version of Adobe Reader. This will ensure you are able to completely fill the form in its entirety and allow you to sign the document before either printing or sending the form electronically by email to one of our staff. You can download Adobe Reader for free by clicking on the appropriate link: Mac OS X and Windows
 

Notice of Privacy Practices

We have also provided the Notice of Privacy Practices for our office here for you to review. You are welcome to print a copy for your records or we can provide a copy at your request. Please take a look at it before you come in for your appointment. You will be asked to review and sign it when you are here for your visit.
 
Acknowledgment of Receipt
 
Cancellation and No-Show Policy
 
Refund Policy