New Patient Forms

We look forward to having you as a patient and would like to take this opportunity to thank you for choosing us to participate in your healthcare. Please complete and sign all appropriate forms and bring these with you for your first visit.

Your insurance company may require prior approval from your primary care provider for a consultation. If this is the case, you must obtain this prior to your appointment.

We accept cash, checks, debit cards, and most major credit cards. Please be prepared to pay your co-pay and coinsurance at the time of service.

You have been given a check-in time 30 minutes before your appointment time to process the information you have provided. We greatly respect your time and make every effort to stay on schedule for all patients. Please review our Privacy Statement and No Show/Cancellation Policy for important information prior to your appointment.

Dr. Lewiecki Forms

Consultation only Consultation with DXA-Medicare Consultation with DXA-Other Insurance

Additional information from other doctors will be necessary in order to evaluate your condition.
Please bring with you or ask your physician to send us the following:
> All previous bone density tests (original printouts are preferred to copies)
> Laboratory reports
> Office and hospital medical records regarding any bone problems
> X-rays, CT scans, and MRI reports
Please be advised, our office will contact you two days prior to your appointment to verify you have all requested information for your appointment. If you do not have all your information, your appointment may be rescheduled.

Dr. Rudolph Forms

Consultation only Consultation with DXA-Medicare Consultation with DXA-Other Insurance

Additional information from other doctors will be necessary in order to evaluate your condition.
Please bring with you or ask your physician to send us, the following:
> All previous bone density tests (original printouts are preferred to copies)
> Laboratory reports
> Office and hospital medical records regarding any bone problems
> X-rays, CT scans, and MRI reports
Please be advised, our office will contact you two days prior to your appointment to verify you have all requested information for your appointment. If you do not have all your information, your appointment may be rescheduled.

Julia Chavez, CNP Forms

New Patient

Please print, fill in, and bring the following to your appointment:

New Patient Form
Insurance Cards
Prior Records (This is helpful, but not required)

Becky Whittenburg, CNP Forms

New Patient

Please print, fill in, and bring the following to your appointment:

New Patient
Insurance Cards
Prior Records (This is helpful, but not required)