New Patient Forms

Thank you for scheduling your first appointment with Dr Lyndon G. Johansen. We hope you will feel comfortable and secure with the treatment you receive from our office.

Prior to your first appointment please take a few minutes and complete the following papers, which you will need to bring with you at the time of your appointment.

REGISTRATION form. Please fully complete this form and sign the ASSIGNMENT AND RELEASE section.

Patient Medical Information. Dr Johansen will use this form to review your past medical history. Fill out this form the best you can. If you have any questions on this form please ask Dr Johansen. This will become part of your confidential medical record in our office. All your medical records are confidential. We can release your records only if you give us written permissions.

Medical Insurance Disclaimer (included in the Patient Consent). This states that if for some reason your insurance company denies payment for a non-covered service with Dr Johansen, you are liable for that charge and we will bill you for the balance. Payment will be expected within 30 days unless prior arrangements have been made.

Patient Consent For Use and Disclosure of Protected Health Information. This is the privacy act that the government has put into place please sign this form. We have a four page explanation letter that we would be very happy to let you read when you come into the office.

It is important that at the time of your appointment you have your insurance card, photo id, co-pay and referral, if applicable, with you so we may bill your insurance company. Please notify your receptionist of any changes in your insurance, primary care physician or addresses.

It is our office policy to collect co-pays and deductibles at the time of service. We accept check, cash and credit or debit cards.

Refer to the Directions link at the left where you will find a map showing where we are located and descriptions on how to get here.

Thank you again for choosing to see Dr Johansen. We are looking forward to working with you.

downloadNew Patient Forms

 

Word Document DownloadAuthorization to Disclose Medical Records Form