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Forms

Please Note: these forms are in Acrobat format. Please download the free Adobe software to read and print them.

Adult form (fillable form to be sent using instructions below)

Adult form (to be printed and filled out by hand)

Pediatric form

Please note that for initial visits with Hannah Caruso, fill in a consent form she will provide you with at the time of your first visit.

 

IMPORTANT NOTE

The fillable version of the adult form is a fillable PDF document and will need to include your electronic signature prior to sending. When you click the link above, the form will open in a popup window, but it is not possible to fill in the form in this viewer. You must download it to your computer and open it in Adobe Acrobat Reader. Click here for instructions on how to sign the document.

INSTRUCTIONS FOR SENDING
THE COMPLETED FILLABLE FORM

To comply with federal security and privacy (HIPAA) regulations, the electronic transmission of your personal health information must be done securely. Please follow these steps to send us your completed form.
STEP 1:
Click this button and select the PDF file that you have filled in and saved.


STEP 2:
Click this button to encrypt the file. Encrypt File

STEP 3:
Click this button to download the encrypted file. It will be saved as "adult_form.pdf.encrypted". Depending on your browser settings, it may be saved to your default download folder without any prompt; otherwise you will see a dialog with options to save or open the file, in which case you should choose the save option. You can save it in any folder you want, but DO NOT CHANGE THE FILE NAME. Download File

STEP 4:
Enter your name, then click Choose File to select the encrypted file you just downloaded, NOT the original PDF. Then click Send File to send it.

Name:  

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