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New Adult ADHD Patient /
Family And Insurance Information Form


Today is Saturday/24/06/2017

 

What is your Gender?

*Attenion: If you do not include a proper home address in the fields below, you're form will be discarded/deleted immediately. Answers such as n/a are not acceptable answers. We need a complete and accurate address to be able to bill you for our services, as well as creating a medical record for you.

 

 

 

 


* Please read the following statements and check the boxes if you agree.

Meaningful Use Form


 

This office may ePrescribe (send prescriptions electronically to your pharmacy) and view my external history prescriptions (prescriptions written by other doctors).

 

How would you describe the patient's ethnicity? If you are uncomfortable answering the questions, you may select "Decline to answer".

I authorize Vinaya K. Gavini MD to release any medical records when I request them to be shared.

 

Notice of Privacy Practices


I have read and agree with the above notice of PRIVACY PRACTICES.

 

Questionaire


 
 

 


ADD Questions


 
 
 
 
 
 
 
 
 

Clinic Hours

Mon: 8am-6pm
Tues-Thurs: 12pm-6pm
Fri: 8am-2pm
Sat: 8am-12pm
vgavinimd@yahoo.com

Gavini ADHD Clinic

26850 Providence Parkway
Suite 300
Novi, Michigan
48374
(248) 348-4200