ACTCM PATIENT FORMS

You may print these forms to fill out at home before your first visit.

1- Initial Intake

2- HIPPA (Notice of Patient Privacy)

3- HIPPA Signature (receipt of Patient Privacy HIPPA Policy)

4- Lifestyle Questionnaire

These forms are here for your convenience. These forms must be filled out before treatment is given to first time patients. You can print these forms out by first clicking on each form and selecting either "open" or "save to disk" You can save this to a convenient place where you can retrieve it (usually to your desktop for easy access). Locate and open these forms up(the files are in “Microsoft Word”). From here you can print the files and fill them out and bring these with you to your initial visit.

If you are having difficulty downloading these forms please email ACTCM and the forms will be emailed to you directly.

If you have any questions or comments please email: ACTCM@actcm.net

Or call (585)-458-6190 if you need further assistance.

595 Seneca Parkway, Rochester, New York 14613