Forms and Policies

The following forms will need to be downloaded and completed, depending on your particular situation. Please contact us if you have any questions as to which forms you will need to complete. Once completed, please either bring with you to your appointment, email the completed forms to [email protected], or call us at 203-900-3996.

To view these forms, you will need the free Adobe Acrobat Reader, available for download here: get.adobe.com/reader/

New Patient Forms

• Patient Registration
• Payment and Cancellation Policy
• Notice of Privacy Practice
• Email Authorization Form
• Patient Agreement and Individual Treatment Plan

Workers Compensation Forms (For New York Patients)

• C-4 Form This form is filed within 48 hours of first treatment.
• For continued treatment, use Form C-4.2
• To report permanent impairment, use Form C-4.3
• HIPAA Authorization

Auto Accident and No-Fault Forms (For New York Patients)

• No Fault Form NF 2
• No Fault Form NF 3
• Assignment of Benefits Form
• HIPAA Authorization
• Medical Lien

Other Forms (Interventional Pain and Regenerative Medicine)

• Release of Records
• Policy on Blood Thinners and Spine Procedures
• ASRA Guidelines for Patients on Blood Thinners
• Opioid Treatment and Patient Agreement Form
• Opioid Contract Agreement
• New Patient Questionnaire

Other Forms (Venous Medicine)

• Release of Records
• New Patient Questionnaire
• Chronic Venous Insufficiency Screening Form (English)
• Chronic Venous Insufficiency Screening Form (Spanish)

Other Forms (Cosmetic Medicine)

• Release of Records
• New Patient Questionnaire