Patient Forms

​If you have insurance, please bring your insurance card or other proof of insurance. If you do not have insurance, please contact our business office at 414-640-5433 before your first visit.

 

For Sliding Scale discounts bring proof of income, such as  pay stub, income tax form, letter from employer

Download, print and fill out the following form and bring them to your first appointment.

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• ​New Patient Forms - ALL

 

• Individual forms downloads:

  • New Patient Form - Demographics​

  • New Patient Form - Fee Policy​

  • New Patient Form - Insurance​

  • New Patient Form - Release of Information

  • New Patient Form - PHI Consent

  • New Patient Form - General Informed Consent for Treatment
     

• Clinical / Medical History

  • Medical History Form​

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• Telemedicine & Automated Messaging

  • Telemedicine & Automated Messaging Consent​

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Please email completed forms to contact@shalemhealing.org