Registration Forms

 

2020 INSTRUCTIONS

During the Coronovirus pandemic, we have decided that we will NOT have patients complete forms.  Please do not bring forms into the office at this time.

Instead, if we don't have consents on file, we will ask for verbal consent:
 - to treat you
 - to file a claim
 - to have your insurance payment paid directly to our practice

You may obtain a copy of our privacy practices at any time in our office on on our website.

 

VIEW Forms Here:

PRINT Notice of Privacy Practices Acknowledgement of Receipt & Communication Practices (You will find our Notice of Privacy Practices under the Policies tab.)
PRINT Consent to Treat & Assignment of Benefits / Financial Policy
PRINT Health Form

 

 

 


 


         

Copyright © 2020 Laura Wagner, MD. All Rights Reserved.
14377 Woodlake Dr. #111 • Chesterfield, MO 63017
314-434-1111