23 Shackleford Drive Ste A Little Rock, AR 72211


Patient Forms and Resources

Patient Resources

When scheduling your first time appointment, we ask you for a valid e-mail address. This is primarily used as a tool to communicate with you about future appointments, announcements, etc. However, for your first time appointment, it will also be used to send you electronic versions of our new patient forms. There will be no printing necessary, unless you cannot complete a Microsoft word document on your computer. Be sure to e-mail your forms to [email protected] once they are complete or bring the printed copy in with you for your first appointment.

You will receive an e-mail with electronic forms attached before your scheduled new patient appointment.

You can also access our electronic forms and complete them here:

New Patient Questionnaire

Insurance Update Form

If you do not have an e-mail address, did not provide one when setting up your first time appointment, or did not complete the electronic forms, we have paper versions available upon check-in at the office. Please arrive approximately 10 minutes before your scheduled appointment time, and if needed, we will be happy to assist you with these. There is a link to the new patient forms here for your convenience as well.

For patients who would like to set up or modify auto-draft payments, please print and fill out the form below.

Auto Draft Authorization Form

Auto Draft Authorization Form

Please complete this form if you wish to have your monthly bill automatically drawn from your credit card or debit card.

*Individual results are not guaranteed and may vary from person to person. Images may contain models.