Please download, print, complete and sign the following documents prior to your first consultation with Dr. David Greenfield for treatment. This allows us to use your initial consultation time as effectively as possible rather than spending part of that time completing administrative paperwork. These forms must be completed prior to meeting with Dr. Greenfield. All necessary forms are available for download and printing below.
You may bring forms directly to the office or fax or email them to CITA.
Fax #: 860-561-8424
Click on the link name to view the form as an Adobe Acrobat document (PDF). Right-click on the link name to save and download the form. If your forms are not printing correctly, make sure your printer’s “Scaling” option is turned off. On a Macintosh, enable the option to “Ignore Scaling and Shrink to Fit Page Width.”
- 1 – Registration Form
- 2 – Adult History Form
- 3 – Patient Record Disclosures
- 4 – Assignment of Benefits
- 5 – HIPAA Connecticut Notice Form (Review Only, Do not Print)
- 6 – HIPAA Information Acknowledgement Form
- 7 – General Practice Information Consent Form (Review and Print Last Page Only)
- 8 – Child and Adolescent Developmental History Form
Note: To download Adobe Acrobat Reader for free, click here.
Unable to download or print the patient forms? If you have tried troubleshooting and still cannot download any of these forms, please contact us at 860-561-8727 to request copies be sent by email.