New Patient Form

Doctor in Snellville, GA

  • Patient Information

  • Guardian Information

  • Emergency Contact

    In case of emergency who should we contact? Please provide at least one contact.
  • Person #1
  • Person #2
  • Person #3
  • Health History

    Check if you have or had any of the following:
  • Recent Tests

    When did you last obtain the following tests?
  • Lifestyle

    Please answer the questions below.
    Tobacco History
  • Alcohol History

  • Recreational Drug Use

  • Current Medications

    If applicable, please list the names of medications and/or supplements and how you are taking them.
  • Allergies

    If applicable, please list and describe your allergies.
  • Family History

    Please fill in age of family member when first diagnosed. Also, list type of cancer.
  • Mother
  • Father
  • Brother
  • Sister
  • Current Symptoms

    Put a check mark next to any symptom you are currently experiencing. If no symptoms check none.
  • Acknowledgment

    Permission to Treat & Release of Information
    • I give my permission for medical treatment. In compliance with state regulations and in order to facilitate optimal healthcare for you, we are required to make a reasonable effort to inform you about your lab results procedure outcomes and final x-ray reports. (The only test we may not discuss over the phone is HIV testing).
    • I give permission to contact me via telephone to discuss my diagnostic test results.
    • I authorize Mountaintop Health Care Company to release any information regarding my examination or treatment for the purpose of obtaining insurance compensation, pre-certification, or medical records.
    • I authorize any other medical facility to release all medical records including x-rays, laboratory results as well as any office notation that may be important for any medical treatment.
    • I hereby further consent to the clinic sharing information regarding me and my treatment with clinics affiliated with this clinic if I should seek medical attention or treatment at any such affiliated clinic.

    Mountaintop Health Care Company’s Financial and Insurance Policy


    • For self-pay patients, my practice operates on a fee-for-service basis. This means that your fee for each appointment will be due at the service.
    • Initial Appointment: (Physical Exam, Screening, Assessment, and Instructions): $150

    • When you make an appointment with me I ask that you provide me with as much notice as possible should you need to cancel or change an appointment, by calling my office phone at 470.395.3618
      • Cancellation 24 hours or more before appointment: No charge
      • Cancellation less than 24 hours before appointment: $25.00
      • Cancellation without notice (no-show): $50.00
    • The associated fee must be paid prior to rescheduling an appointment.
    • I have read and understood the office policy stated above and agree to accept financial responsibility described.
    • I have read all the information and have completed all the requested information.
    • I certify that this information is true and correct to the best of my knowledge.
    • I give permission to contact me via telephone to discuss my diagnostic test results.
    • A photocopy of this authorization shall be valid as the original.