(319)320-8910

First Street Community Center
221 1st St NE
Mt Vernon, IA 52314

                              NEW CLIENT FORMS  

In preparation of first appointment:

  1. For adult patients, fill out top four forms and bring to the initial session. For child, 'Adult' form is NOT needed.(Please do not send as unsecured email)

  2. Bring Insurance Card, if using pre-approved insurance. (Patient is encouraged to contact Insurance Provider for pre-authorization prior to first appointment.)

  3. Credit card, HSA, cash or check are acceptable forms of payment at time of service.

CONSENT TO TREATMENT

PAYMENT OF SERVICES

CLIENT INSURANCE INFORMATION

ADULT INFORMATION

CHILD INFORMATION