Forms

*Dr. Jacob has a secure online portal where new patient forms can be completed electronically. You may provide Dr. Jacob with your email address if you would like to receive the link to complete the forms electronically. If you have scheduled a new patient appointment and have not yet received this portal link, please contact Dr. Jacob. Alternatively, you may print the new patient forms from below, complete them by hand, and bring them to your initial intake appointment.
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​The following forms are to be completed prior to the first appointment. Other forms will be completed as needed.
- New Patient Form (Either Child or Adult)
- Informed Consent & Outpatient Services Contract
​- Acknowledgement of Notice of Privacy Practices

New Child Patient Form

New Adult Patient Form

Informed Consent & Outpatient Services Contract

Notice of Privacy Practices (Read Only)

Acknowledgement of Notice of Privacy Practices

Release of Information

Consent for Email Communication

Consent for Skype