Patient Forms & Fee Schedule

Please do not fill out forms until you have received an official appointment confirmation letter from our office.

Intake Forms for New Patients 

Please click the appropriate link below depending upon which doctor you are going to see and you will be directed to the appropriate form.   If you run into difficulty please contact the office.

IMPORTANT: Please use the most updated version of Safari or Chrome when you complete the online Intake Form.  Click here to download Chrome (For PC’s or Macs) or Safari.  (For Macs)

Care Agreements

Establishing clear agreements is an important part of having a healthy relationship. Please fill out and bring to your first appointment. Questions or clarifications can be discussed with our front office staff.

Medical Records Request
Reviewing your medical records, helps us make the most of your initial intake. Medical records will be reviewed if they are received in advance. Please make arrangements using the medical records release form. Fax or send the form to any relevant care providers that you are currently seeing and/or from the past five years.

Medicare Opt out form
If you have Medicare in any form, we require you to fill out our Medicare Opt-Out form, stating that you are aware that we cannot take your Medicare.

Additional Forms for Dr. Lichtig – download, print, fill out and bring to your visit

New Patient Deposit
A $150 deposit is required to hold your intake appointment in our physician’s schedules. Payment is accepted by check or over the phone by credit card.

Medications, Supplements and Herbs
Please remember to bring in the bottles of all medications, supplements and herbs that you are currently taking to your initial appointment.

Fee Schedule