Riegler-Shienvold & Associates: Forms

Forms

Completing the necessary forms in advance of your first appointment will expedite your visit. We have several forms that are used in our office. They are available here to view and print to bring with you.   Please complete all information on the forms in the name of  the identified patient.  Note: You must have Acrobat Reader to open the forms.

  1. Patient information  (please complete form, print, and sign as indicated)
  2. Health & Wellness Intake Questionnaire  (please complete and print)
  3. Provider-Patient Services Agreement  (please read and keep for your records)
  4. HIPAA Privacy Addendum (September 23, 2013)  (please read and keep for your records)
  5. Riegler Shienvold & Associates financial policy (please print and sign)
  6. Services Provided Outside of Office Not Covered by insurance   (please print and sign)
  7. Developmental History  (complete and print for children under the age of 17)
  8. Release for treatment of Minor Child  (complete and sign if instructed by office staff)
  9. Authorization and Release for treatment of Adolescent Child (age 14 to 17)