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Becoming a Patient

 

Patient Registration Form

We would love to welcome you to the Alpstein Clinic. The first step in becoming a patient is to fill out the form below. Once received, one of our Patient Coordinators will be in touch with you to answer questions and provide detailed information about scheduling and the preparation of your personalized treatment plan and program.

Patient questionnaire

Section 1/5: Personal Information

Contact Information

Consent

Additional Information

Information Regarding Wheelchairs

Section 2/5: Emergency Contact

Section 3/5: Medical History

Illness

Allergies and Habits

Dental Information (Multiple choice possible)

Attending Doctor

Section 4/5: Insurance

Type of Insurance*

Section 5/5: Final Information

Terms & Conditions*

Newsletter

Misc.