Online Forms

Patient Registration

You may preregister with our office by filling out our secure online Patient Registration Form. After you have completed the form, please make sure to press the Complete and Send button at the bottom to automatically send us your information. The security and privacy of your personal data is one of our primary concerns and we have taken every precaution to protect it.

Credit Card Authorization Form

While we prefer to have a credit card physically on-site, we understand that some patients, such as students or those travelling away from home, may not have the card available. Please use the below credit card authorization form to give us all the information we need to process your credit card for payment while adhering to legal standards that protect both you and our practice. We must have all of the information requested on the form in order to process the payment. This form is NOT required unless you will not have your credit card with you on the day of your visit. Please read more about our financial policy here.

Medicare Private Contract

For your convenience, we have made our Medicare Private Contract available online in case you would like to review it well in advance of your appointment. This contract is not valid unless both the patient/POA and Dr. Levine have signed and dated it.