Online Patient Form

You have probably already received the necessary paperwork through your child’s school, however if you have misplaced it or need additional copy, we have provided it here for your convenience.  You may either print this out and send it in with the child or fill it out here and it will be electronically sent to us.  If you fill it out electronically, this must be done 2 business days prior to your visit.  If you are uninsured and paying out of pocket, please send payment indicated on the day of service with the child. Otherwise, we will file your insurance claim on your behalf and bill any remaining balance owned.