Dr. Gangemi’s New Patient Forms

By clicking on the below links you can read my Office Policies and Procedures (includes appointment fees), as well as the New Patient Forms and HIPAA NPP form. New patients are scheduled for a 2-hour time block initially with 2 follow-up appointments, one hour each. Out-of-area patients should plan on spending 2 consecutive days in town so I may follow-up with you the day after (or 2 days after) your initial appointment. Please call the office for information about local accommodations.

Please download the following New Patient Forms to fill out once we have called you and arranged an appointment time.

• At least two weeks prior to your appointment – return signed Form 1A or 1B
• To bring in with you during your appointment –
  1. Form 2A (Male or Female) or 2B for children under age 4
  2. Form 3.0 HIPAA NPP
  3. Form 4.0 (suggested, but not required)

Please make sure you print the correct forms. If you are not sure please call or email us.

• 1A: Policies & Procedures:
  Please choose either of the following to submit at least 2 weeks prior to your appointment:
  Sign and return the Policies & Procedures via email ([email protected]) OR eSign this form directly online at this link.
• 1B: Policies & Procedures For Special Circumstance Appointments:
  Please choose either of the following to submit in order to schedule your appointment:
  Sign and return the Policies & Procedures For Special Circumstance via email ([email protected]) OR eSign this form directly online at this link.

• 2A: Adults and Children (age 4 and up!) New Patient History Forms:
  (MALE FORMS / FEMALE FORMS)
  Please print, fill out completely, and bring in with you during your appointment along with lab work, supplements, medications, and any orthotics & common footwear.
• 2B: Children Under Age 4 and Those With Developmental Delays New Patient History Forms:
  Please print, fill out completely, and bring in with you during your child’s appointment along with lab work, supplements, medications, and any orthotics & common footwear.

• 3.0: HIPAA Notice of Privacy Practices:
  Please print, read, and sign the last page of the form and bring in with you to your first appointment (required).
• 4.0: Email Correspondence Form:
  Please sign this form and bring in with you to your first appointment (suggested but not required).