Patient Forms

Please download, print, fill out, and sign the following documents prior to your first consultation with Dr. David Greenfield for treatment.

You may bring them directly to the office or fax or email them to CITA.

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 “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 FormY
• 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.