Forms to be Completed Prior to First Appointment
Please Print Out and Complete the Following Forms Prior to Your First Appointment.
Adult Intake Packet or a Child Intake Packet
1. Practice Policies and Agreement
2. Insurance Information Form
3. Authorization to Obtain and Release Information Form
Please print out and fill one out each for
your primary care doctor or pediatrician
your therapist (if applicable)
anyone else you wish for me to communicate with, send, or receive records from (school, another healthcare provider or institution)
4. Child / Adolescent Intake Form OR Adult Intake Form
5. Please review my Notice of Privacy Practices
Card on File for Payment
Vanderbilt ADHD Parent Rating Scale
Vanderbilt ADHD Teacher Rating Scale
Your privacy is of the utmost importance to me. In general, I do not keep physical records which are prone to theft and fire. In addition to physical security and shredding, I utilize several services that increase your privacy while still maintaining record keeping and communication requirements.
Copyright © David Penner MD PLLC. All rights reserved.