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.

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 2001 S. Shields Street, Building A, Fort Collins, Colorado 80526.

New Patient Forms Required Before Scheduling Appointment

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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.

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Optional Forms

Medical Records Release  

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