If you are a new patient, please download and print the following forms prior to your initial diagnostic examination visit at MHRPA. Thank You!
New Patient Intake Form
This form is used to collect contact information for you and your spouse (if applicable), emergency information, and your information about your dental and medical history.
Head Health History Form
This questionnaire is used to capture critical information vital about your head health history, dental work you’ve had that relates to your dental forces, pain symptoms and locations, traumatic accidents, lifestyle and habits.
Headache History Form
This questionnaire is used to collect information about your health and headache history, including any previous diagnoses and testing, medications you’ve taken, pain locations, severity and intensity.
HIPAA Authorization Form
Your health information is protected by law. Signing this form grants us consent to use your health information. We use this information to secure stronger insurance reimbursement whenever possible.
Notice of Privacy Practices
Please read this document as it describes how health information about you may be used and shared, and how you can access this information. Your privacy is important to us!