Intake Forms

We require that all potential patients complete all of our intake forms and request at least 2 years of medical history from prior providers to be sent to us. Once these are done, we will contact you to schedule your intake appointment. The process is the same for both local and out-of-state patients.

Patient Consent and Notice of Receipt of Privacy Practices

This form allows Lighthouse to use and disclose protected health information to carry out treatment, payment and healthcare operation. It also verifies that you understand you have the right to review the Notice of Privacy Practices.

Time to complete: 1-3 minutes

Patient's Informed Consent Document for Testing and Treatment

It is important that you read and understand the information contained in this form so that you can make an informed choice about being treated at Lighthouse Complex Care Clinic. It is your consent for treatment and verifies that you understand several key components of our care model and treatment methods.

Time to complete: approximately 5-10 minutes

Lighthouse Complex Care Intake Form

This form includes questions about current health and medical history which are critical to helping us understand your (or your child's) needs. This must be filled out completely and accurately before we can schedule your appointment.

Time to complete: approximately 30-45 minutes