For Security and ant-spam purposes, we have moved this form to our other site newclientform.com. This will allow ease of use and (hopefully) less robot spam. Upon completion of the form you will be returned to our main site and the authorization options.
Thank you.. Dr. B
Step 1: Please fill out this Registration Form so we have your information on file and automatically entered into our system so Karen does not need to re-type it, creating less work and less chance of errors. Once it has been submitted you should be taken on to our Authorization Page:
Step 2: Complete the Authorization by printing and faxing or by filling it out and signing it Electronically. You should be taken to that page once this form is, successfully, submitted.
If not, Click Here for Authorization Page.
Once we receive BOTH the Registration Form AND signed completed New Client Authorization, we will create your client file and contact you for an appointment. You should hear from our office upon submission of this form (make sure you have a valid e-mail) within 24 hours. If not, please call Karen at 305-652-5372 or e-mail firstname.lastname@example.org.
New Client Registration Form (10-2014)
Fill out the information below, items marked with a red asterisk * are required and the form will not submit without them. Do the simple math test at the bottom to avoid spam (see note below on Safari browser issue) and press submit. After successful submission, it will take you to the Authorization page – if does not, check the top for a warning to see if you missed a required entry.
Safari users – the simple math test at the bottom helps us avoid spam. If it is not working for you and you are using Safari browser, please try a different browser as there seems to be an occasional problem with safari. If you still have the problem (not taking the math answer) and you are using a different browser – please print this form and fax or email it to us. We are working on the programming glitch and it is very rare.
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