Patient Intake Forms and Consents

Patient Intake Forms and Consents

Patient Intake Forms and Consents for patients interested in receiving services and care from Hale Healthcare.

Many intake forms are available through the patient portal.  You can fill them in and sign forms by typing your name.

If you are unable to complete forms in the patient portal, please fill these out below and bring them with you for a speedy check-in.

Remember to bring in a picture ID and a copy of your insurance card if you will use it.

We accept credit cards, checks, cash, money orders for payment. Hale Healthcare does not keep cash on the premises and is not equipped to do so.

If you want to pay with cash, please bring exact change.


Patient Intake Forms and Consents

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All Patients Complete the Following Patient Intake Forms and Consents:

Patient Intake and History

Hale Healthcare Welcome: Office Policies and Procedures

Hale Healthcare Elite Membership Agreement

Hale Healthcare Financial Liability Form

Hale Healthcare Credit Card Authorization Form

Notice of Privacy Practices

If you wish to have your medical information shared, please indicate in the form below.  If you would like a copy of your medical records printed, you will be charged a $20 fee.

Medical Records Request/Release Form

Patients for Buprenorphine Therapy Complete the Following:

Buprenorphine Therapy Agreement

Buprenorphine Patient Questionnaire

Patients for Medical Aesthetic Procedures Complete the Following:

Confidential Skin Health Survey for Medical Aesthetics