Medical History (pdf)


Registration Form (pdf)


Workers Comp Verification (pdf)


Privacy Rights Acknowledgement (pdf)


Release of Information Authorization (pdf)


Fees & Payment Policy

Our Fees are based upon what is the usual and customary charge for this area, the complexity of the problem, the materials required, and time spent on the service. We strive to charge fairly, but if you have a question about any fee please ask.

Payment is expected at time of service. We accept cash, check, or credit card. In all instances responsibility for payment is yours alone.


Insurance is a method of reimbursement, not a substitute for payment. For those with insurance that we accept, we will be happy to bill your insurance company. You will be requested to pay for any services or products not covered by insurance, any copay, and any deductible not met at the time of service. Once we have received a response from your insurance, any remaining balances will be due and payable by you. A deposit of any unmet deductible amount will be required prior to scheduling elective surgery.

Self-pay patients: payment is expected at the time of service. If you have difficulty with payment in full, arrangements can be made for a payment plan. Deposits will be required prior to scheduling elective surgery.

Workers Compensation: We require written or verbal verification from your employer or the WC carrier. If we do not have this at the time of appointment, we will treat the service as self-pay; or we will reschedule your appointment to allow you opportunity to obtain verification.

Disability forms: We will complete an initial disability form that you provide at no charge. Thereafter, we will charge $5 for each form completed to be prepaid.

Medication Refill Notice

 Medication refills should be obtained while in the office during your appointment. For unforeseen refill requests, the physician will be asked (at times set aside each day for such requests) and either your pharmacy will be called or you will be notified that your request cannot be filled. Medication refill requests can be considered only during office hours when the charts are available.