Patient Forms

For NEW or RETURNING patients: Please download the Intake Form, review and complete. You can email the completed form to adminstaff@shifatherapeuticsllc.com, ATTN: Intake Specialist - patient name in the subject line.

You can also bring the completed Intake Form with you on the day of your appointment.

The Release of Information form allows for the release of various patient account related information to an entity/individual of choice designated by the patient/parent/guardian. The patient must select a time period of when the release shall be enacted and when it will expire.

Patients 18 years of age and older should complete and submit a release/authorization form if they wish to grant another individual(s) access to their account information.

Please download the pdf doc, read and complete. You can email the form back to us at adminstaff@shifatherapeuticsllc.com and type “ROI - patient name” in the subject line, or bring completed form to our office in person at your next appointment.