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Forms
   

Forms

Note: All new patients must print and complete new patient forms.

*Adults (being evaluated) - please complete Adult History and Adult Checklists.
*Children/Teens- Parent completes Child History and Child Checklists.

New Patient Forms
 
Patient Information  
Policy Statement and Fees  
Privacy Statement  
Release of Information
Credit Card Authorization
*Child History  
*Teen/Young Adult History (completed by teen/young adult being assessed)  
*Child Checklists  
*Adult History  
*Adult Checklists  
These forms are printable PDF's
 
IF YOU ARE SEEING DR> DEWITT, PLEASE COMPLETE THE FOLLOWING

1. Patient Information (above)

2. Privacy Form (above)

3. Consent for Treatment     


 
12625 High Bluff Drive #202 • San Diego, CA • 92130 • Phone (858) 481-4988 • Fax (858) 792-5095
 
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