Prior to your appointment, it would be helpful for you to fill out our new patient forms, which you can fax or mail to us, or bring it with you on the day of your consultation.
Patient Forms
There are three ways to fill these out:
- You can fill them out online and then print them
- You can download them, fill them out in Adobe Acrobat, and print from there (which allows saving if you want to start filling out a form and then come back to it later to finish)
- You can download, print, and fill out by hand
Please note that if you fill them out online and then download them, the downloaded forms will not show anything you may have already filled out online.
Please bring your completed forms with you and give them to reception when you check in.
All New Patients
(and those who haven’t been seen in the last year)
- Patient History
- New Patient Demographics
- New Problem for which you are seeing Dr. Shah (this form is important to provide details regarding what you will be seeing Dr. Shah for)
- Notice of Privacy Practices (only the second page needs to be printed, filled out, and returned)
- Financial Policies and Consent To Treat Form (only the last page needs to be printed, filled out, and returned)
For Parents & Guardians
- Consent to Treat Minor in Emergency if Parent not Present
- Consent for Minor Care with Authorized Guardian
Follow-Up Patients
- Prior to your follow-up visit, if you had an injection or procedure, please complete the Follow-Up Visit form
Billing
For any billing inquiries, please contact BASS Medical Group Billing Department at (925) 627–3424.