Patient Forms

When we receive your completed forms, they will be processed and one of our staff will contact you to arrange an appointment. If you have difficulty downloading the forms or would like to speak directly with our office staff, please call 610-625-1486

It is important that we have accurate information about you, your medical concerns and medical history. Below you will find downloadable forms that every new or continued patient might need to complete prior to scheduling an initial appointment with Ethos Clinic.

Please fax completed forms to: (570) 392-6143.

Informed Consent for Minors

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Court Waiver for Minors

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Let’s Get Started!

Below are various forms you’ll need to fill out and sign and bring with you to your first appointment.

Intake Forms

HIPAA Consent

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Our Notice of Privacy Practices provides information about how we may use or disclose protected health information

HIPAA Data Use

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Release/Obtain Health Information

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Release/obtain information from Medical records pertinent to the Mental Health/Mental Retardation; Drug/Alcohol treatment; and or HIV/AIDS treatment.

Patient Consent for Electronic Prescribing

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Ethos Clinics has implemented e-prescribing as part of an on-going effort to improve your health care. It is a system used to submit prescriptions electronically to the pharmacy of your choice.

Opioid Medications

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Pain treatment with opioid medications: patient agreement.

 

Informed Consent for Counseling and Psychotherapy

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As we work together there are a list of ways in which we will work with you. This form outlines what you can expect during your time with Ethos Clinic.

Policy

Medication Policy

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Please call with medication refill concerns at least 1 week prior to completion of current prescription in order to prevent gaps in medication Refill requests will be processed within 2 business days 48 hour period

Paperwork Policy

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Please be advised that no Time Off FMLA or Disability paperwork forms will be filled out for patients who are not established with the practice

Missed Appointment Policy

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In order to provide the best service to our patients we have established the following policy

Duty of Payment

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Ethos Clinics to bill my insurance on patient behalf for payment of services.

ADHD Policy

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Please be advised that Ethos Clinic will not be accepting new adult ADHD patients unless the patient is able to provide a recent neuropsychological evaluation that demonstrates this diagnosis

Call Ethos Today to Book Your Appointment