In order to comply with HIPAA regulations in regards to patient privacy, a signature is required in order to properly submit the Review Intake Form.
Adobe Acrobat PDF or Microsoft Word document
Fill it out, sign it and date it, and e-mail it to us. If you would like to email a copy of the form to us prior to mailing it, please put your surname(s) in the SUBJECT of the email message (i.e. subject of email would be "Review Intake Form - Aronson"). All communications via email please. No physical mail.