Welcome to the Couri Center and thank you for choosing us! To allow us to better serve you during COVID-19, we need the following information at least 24-hours prior to your appointment.
New Patients - Women
- Patient Information Form
- Gynecologic Questionnaire
- Medical Release Form
- Insurance Card (copy front/back)
- Care of Unaccompanied Minor: Consent to Treat
New Patients - Men
Integrative Food Sensitivity Form
Please complete and email forms to: firstname.lastname@example.org.
It is critical we receive these forms at least 24 hours prior to your appointment time.
Print forms and fill in by hand.
- Scan completed documents and email to email@example.com.
Complete forms online as .pdf.
- Please open each form and save it on your computer, preferably add your last name to the file name while saving.
- Open the saved documents and complete each fill-in form.
- Save completed documents.
- Email completed documents as attachments to: firstname.lastname@example.org
Unless canceled at least 24 hours in advance, our policy is to charge for missed appointments at the rate of $40. Please help us serve you better by keeping scheduled appointments.