Patient Forms

PDF Icon
Prior Treatment History Form

Prior Treatment History Form – Please list all prior treatment history before coming to our office for treatment

PDF Icon
Patient Registration Forms

Registration Information, Consent for Treatment, Policies & Procedures, Patient Report, and Symptom Checklist.

PDF Icon
Outgoing Patient Records Form

This form seeks for consent to release our patient’s information to outside organizations.

PDF Icon
Incoming Patient Records Form

Consent to release patient information from outside organizations to our office.

PDF Icon
Credit Card Authorization Form

This secure form will be under lock and key along with your medical records for your peace of mind.

PDF Icon
Assignment of Benefits Agreement

This form states our policies governing insurance claims and requires your agreement before treatment.

PDF Icon
Office Policies

Just a summary of our office policies. We want to be as transparent with our patients as possible

PDF Icon
HIPAA Notice of Privacy Practices

Integrated Clinical Neurosciences proudly follows all HIPAA and privacy practices. Learn how we protect your rights.

Please note: These forms are in Portable Document Format (pdf) and require a pdf reader. If your computer does not have a pdf reader, you may download Adobe Reader X for free here.
Reader X download note: The download is preset to automatically include, for free, both the Google Chrome Internet Browser and the Google Toolbar for Internet Explorer.

These are optional and are NOT required to view and/or print Integrated Clinical Neurosciences/Silicon Valley TMS forms. If you do NOT want them included in your download, be sure to CLEAR the check box called “Yes, install Chrome as my default browser and Google Toolbar for Internet Explorer – optional.(32.11 MB)”.

In Network With
United Healhcare
Anthem - BlueCross
MHN - A Health Net Company
Magellan Health Insurances