1211 West Main Street, Waterbury, CT 06708

Online Patient Forms

The following patient information forms may be printed directly from this site, to be filled in at your convenience prior to your appointment. Please be assured that NO medical information is being transmitted over the Internet.

Medical History Form


Privacy Practices (HIPAA)

Notice of Privacy Practices
(Required by the privacy regulations created as a result of the Health Insurance Portability and Accountability Act of 1996, or HIPAA.)

Acknowledgement of Receipt of Notice of Privacy Practices
(You may print, sign and bring with you to expedite your appointment.

Billing and Insurance

Practice Policies and Procedures

This document provides information on the following topics: