Phone 303-781-0511 | Fax 303-781-0517 | 323 W Drake Rd Suite 200 Fort Collins Colorado 80526

Appointment Forms

Our medical clinic is presently only accepting consultations for deep brain stimulation or patients who have had deep brain stimulation. Patients interested in consultation, second opinion or transfer of care, please complete and send new patient forms below. If your insurance requires a referral, please initiate the referral request from your primary care physician. Copays and/or deductibles are collected at the time of your appointment.

Fax (303-781-0517) or mail your completed forms with a copy of your insurance card. Symptom diaries below are optional, however completing a diary of symptoms is helpful during your appointment. Our mailing address for all clinic locations is 323 W Drake Road, Suite 200, Fort Collins, Colorado 80526.

New Patient Forms Required Before Scheduling Appointment


New Program – DBS Optimization Assessment Appointment Form


Medical Release Form


All new patients must complete the forms and send in for review prior to scheduling appointments. Include a front and back copy of your insurance card and driver’s license or other identification with your photo.

Patient Medication and Follow-Up Form

Please bring an updated medication list to each appointment.


Optional Forms

Parkinson’s Symptom Diary – supplemental form to monitor daily PD symptoms.

Dystonia Symptom Diary – supplemental form to monitor daily dystonia symptoms.

Tremor Symptom Diary – supplement form to monitor daily tremor symptoms.