New Adult ADHD Patient /
Family And Insurance Information Form

Today is Tuesday/16/01/2018


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.





ADD Questions


Clinic Hours

Mon: 8am-6pm
Tues-Thurs: 12pm-6pm
Fri: 8am-2pm
Sat: 8am-12pm

Gavini ADHD Clinic

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