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

You understand and acknowledge that all users of this website are responsible for their own medical care, treatment, and oversight. All of the content provided on the website, including text, treatments, dosages, outcomes, charts, profiles, graphics, photographs, images, advice, messages, and forum postings, are for informational purposes only and DOES NOT CONSTITUTE THE PROVIDING OF MEDICAL ADVICE and is not intended to be a substitute for independent professional medical judgment, advice, diagnosis, or treatment.


The content is not intended to establish a standard of care to be followed by a user of the website. You understand and acknowledge that you should always seek the advice of your physician or other qualified health providers with any questions or concerns you may have regarding your health. You also understand and acknowledge that you should never disregard or delay seeking medical advice relating to treatment or standard of care because of information contained in or transmitted through the website.


Medical information changes constantly. Therefore the information on this website or on the linked websites should not be considered current, complete or exhaustive, nor should you rely on such information to recommend a course of treatment for you or any other individual. Reliance on any information provided on this website or any linked websites is solely at your own risk.

View our Privacy Policy here.

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