Telemedicine Patient Forms

Please read this page carefully
and assure that the required paperwork
arrives as requested for most productive appointments.

No one likes paperwork, but it is a fact of life.  And unfortunately, paperwork and computer work have increased dramatically for us with telemedicine.  So, we are striving to make the process of paperwork and computer work as easy as possible for everyone.  Also, this procedure helps us to keep costs low for you.

Please see Appointment Information for more about the telemedicine procedure.

New Patient Forms

1. Welcome Packet (single-sided)

Return entire packet except intro page and diagram page which we will go over at your appointment.

Only return the Medicare page if you have Medicare.

If the appointment is for your child, then ALL parents/guardians must sign the paperwork; you can use your photo ID.

2. Copy of official photo identification, such as driver's license (just photo side) or passport (just photo page) .

3. Pertinent labs or tests arranged by dates with the most current on top and without staples. 

We do not need duplicate labs over the years; just the most current. 

Also, we do not need previous office notes.

4.  Please MAIL the above items to 26 Dover Trail, Coventry, CT 06238 so that they arrive within one week from NOW.

If your appointment is less than 10 days away, then OK to email the paperwork and most pertinent labs/tests.

Also, please do not mail certified or insured or signature or any other way that requires us to visit the PO in order to avoid a $125 pick-up fee.

Follow-Up Visit Forms

The following forms are needed for each visit "even if nothing has changed."

1. Medication and Supplement List (single-sided)

2. Symptom List (single-sided)

3. Patient Registration (only if your contact information has changed)

Please make sure that the above forms arrive 2-5 days prior to your appointment so that we can get ready for your appointment. 

You can email  ( OR fax them (937-712-3161) OR mail them (26 Dover Trail, Coventry, CT 06238).

Thank you so very much for assuring
that your competed forms and payment arrive as above!

Let food

be thy medicine, 

and medicine 

be thy food.  




Your word

is a lamp

to my feet

and a light

to my path.

~Psalm 119:105



The secret of health

for both mind and body

is not to mourn for the past,

worry about the future,

or anticipate troubles,

but to live in the present moment wisely and earnestly.

~Buddha (paraphrased)