New Patient Form for Private Practice

Are you new in Private Practice?
Do you need a Consent Form /HIPAA Form /Privacy Form / Financial Form???


In my practice I try to keep things as simple as possible and consolidate paperwork as much as possible

This is the only form I use for 90% of my patients:

This New Patient Form serves the following functions:

  • Collect Demographic Information
  • Collect Insurance Information
  • Collect Patient’s Doctor Contact Information
  • Communicate Late Fees / Cancellation Policy
  • Communicate Financial Policy & Billing Information
  • Communicate Privacy / HIPAA / Communication Policy
  • As a consent for Treatment 


It can be fully adapted to your office and your policies. (If you are unsure of what to include in your new patient form you are advised to review it with a lawyer prior to use.)

The form can  be used as a printed form, as an email attachment, as a link on your website or uploaded in to your EMR. 

File Type .doc
File Size 47KB
Number of Pages 2
Product Terms and Conditions

Lisa Hugh - Southern Maryland Dietitian

Lisa Hugh is a Registered Dietitian with a Bachelors of Science in Dietetics from the Indiana University of Pennsylvania. She completed her Dietetic Internship at Hurley Medical Center in Flint, Michigan. She holds a Masters of Science in Health Science from TUI University. She is currently enrolled as a doctorate student in the Business Administration program at William Howard Taft University. She has worked in diverse clinical settings including doctors offices, hospitals, nursing homes, assisted livings, and hospices. Throughout her career she specialized in working with clients who have complex medical issues. She currently works full time in her private practice, Southern Maryland Dietitian. Lisa believes that nutrition is never one-size-fits-all and that nutrition care can help just about everyone feel better and improve their health. She became a Certified Leap Therapist to better understand food sensitivities and how individual ingredients interact with the body. Single was born after Lisa realized just how much work grocery shopping is when you are shopping for a special diet.

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If you don't have a a consent form, financial policies, HIPAA policies or other new patient forms, start here. 

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