FORMS

Please complete the forms below and email them back to Dr. Samadi at EstherSamadiMD@EstherSamadiMD.com 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 2022
Office Policies and Practices 2022
Electronic Communication Consent Form
Patient Billing Form