Forms | Esther Samadi MD

FORMS

Please complete the forms below and email them back to Dr. Samadi at prior to your initial consultation

1) If the patient is:

under 18 years old, please complete the "Patient Registration Form-Child"

Patient Registration Form-Child

18 years and older, please complete the "Patient Registration Form-Adult"

Patient Registration Form-Adult

2) Please also complete the following 5 forms below:

Credit Card Authorization Form

Consent to Treat

Office Practices and Policies 2019

Electronic Communication Consent Form

Patient Billing Form

If you prefer Word doc versions of each form, please email Dr. Samadi.