New Patient Forms

Please fill out the forms below. Note that all of the forms are required except the Sliding Fee Scale. We encourage you to find out if you’re eligible to take advantage of this cost-saving program by visiting our Sliding Fee Scale info page or calling the clinic at 812-269-5092.

Policies:

As you work your way through the forms below, you’ll be asked to acknowledge receipt of our HIPAA Privacy Practices Notice and our Attendance Policy. You can review and download these policies by downloading our Policy Packet.

Clicking each of the links below will open a form in a new browser window. To return to this page, simply close the browser tab and select the next form in the list.

1. Attendance Policy Acknowledgement*
2. HIPAA Acknowledgement*
3. Emergency Contact Information*
4. Patient Registration Form*
5. Patient Health Questionnaire*
6. Release Authorization*
7. Sliding Fee Screening

*= required