New Patient Forms

Downloadable

These forms are required for all Lidocaine and Ketamine infusions. Nutritional infusions only require the first two forms.

All forms can be clicked on, downloaded, and filled out online. 

To expedite things, it is preferable if you email or fax these forms back to us. If that is not possible, you may bring them to your first visit.

Intake Form

Medical History Form

Medical Records Release Form

Provider Referral Form