Welcome to new patient registration! Please complete the following forms prior to your first appointment.
New Patient Registration
You CANNOT BE SEEN until the following forms are completed:
- Informed Consent & Policy Agreement
- Intake Registration
- SF-36 – Bring a copy of the results
- Telehealth Consent – FOR TELEHEALTH ONLY
- Medicare Non-Provider Agreement – FOR MEDICARE ONLY
- Dry Needling Consent – IF YOU THINK DRY NEEDLING MAY BE RIGHT FOR YOU
IMPORTANT INFORMATION ABOUT REGISTRATION:
- Dr. Garner is not a participating Medicare provider. If you would like to be seen for wellness or maintenance programming ONLY and you are on Medicare, then please contact our office before scheduling an appointment.
- Patient Privacy Disclosure Statement: In filling out the patient registration, I understand that EudeMOMia® will maintain my privacy to the highest standards and may use or disclose my personal health information for the purposes of carrying out treatment, obtaining payment, evaluating the quality of services provided and any administrative operations related to treatment or payment.
Medical Record Release Form
If you need to share your medical records from Dr. Garner’s office with another provider, this form must be completed.
For Ayurvedic Consults Only
If any of these forms are needed Dr. Garner will have you complete them at a later date.