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New Patient Paperwork
Prior to your appointment you will need to complete the following forms and return them to our office. Click on the title to download the form.
Confidential Patient Information Fill out as completely as possible, then sign and have someone witness the bottom.
Family and Personal Health History Please complete all three pages carefully and thoroughly.
Case Form or Child’s History The Child’s History is for infants and children under 12. The Case Form is for everyone else. Please complete the appropriate form as carefully and as accurately as possible.
Three Day Food Diary Fill out to the best of your memory now, or as you go during any three consecutive days prior to your appointment. Be sure to include vitamins, supplements, and any medication, as well as water and other beverages.
Office Policies Please read thoroughly and sign and date at the bottom. We are happy to make a copy for you to keep.
Insurance Claim Form If you want us to file claims with your insurance company: sign and date the claim form (boxes 12 and 13 only). There is no need to complete the rest of the form.
HIPAA Privacy Notice and Consent Form Read the Notice carefully then complete the last three pages and return them to us. The rest of the packet is for your records.
Procedures for Taking Homeopathic Remedies Keep this for your information and review it carefully before opening your remedy packet.
Please download and complete the above-listed paperwork and return it along with a copy of your driver’s license and insurance card and a recent photo of yourself (try to send a photo we can keep).
As always, payment is due at the time of service. Please call the office at 502-426-2033 for rates and send your check or money order in the correct amount payable to Dr. Victoria Snelling prior to your appointment. Mailed paperwork must be received no later than 2 business days before your appointment. Please ensure you have included all necessary items and be certain to allow ample time for delivery. Patients coming in for face-to-face appointments may bring completed paperwork with them.
We are happy to file insurance claims for all of our patients and will either apply payments to your account or reimburse you as soon as the checks come in. Please let us know which option you prefer.
We do have a cancellation policy which is detailed in the Office Policies. If for any reason you are unable to keep your appointment, we require 24 hours advance notice. Out-of-Town cancellations (Dr. Snelling’s trips to Memphis and Nashville) require notice by the Tuesday prior to the appointment. A NO-CALL/NO-SHOW WILL BE CHARGED FOR THE FULL AMOUNT.
For Telephone appointments: On the day of your appointment you will need to call our office at the agreed time.
For In-Office Appointments: Please plan to arrive 15 minutes prior to your appointment so that we may assemble and review your file.
For Out-Of-Town Appointments: You will receive a reminder letter about 1-2 weeks prior to your appointment. This letter will include information about where to go for your appointment.