INTAKE FORM
 
 
 

24 HOUR EMERGENCY SERVICE IS AVAILABLE FOR TREATMENT IN THE FACILITY.
(FEES APPLY)

.
ONLINE INTAKE FORMS
1-please fill out and sign all 4 forms for your convenience
2-you can fax or email once you have signed all forms.
Soon you will be able to directly transfer all forms online

 

English

MEDICAL HISTORY Online PDF
PATIENT INFORMATION  Online PDF
PATIENT INFORMED CONSENT Online PDF
PRIVACY FORM Online PDF


1-follow the above instructions with these 4 forms

Spanish

MEDICAL HISTORY Online PDF
PATIENT INFORMATION  Online PDF
PATIENT INFORMED CONSENT Online PDF
PRIVACY FORM Online PDF

 

      phone:702-450-3371
      fax     :702-633-6079
      email  pleasantsmiles@drathari.com