Forms

These forms can be downloaded and filled out prior to your appointment.  You may either mail them to us, fax it or bring them with you on the day of your appointment.

New Patient Information Form

Financial Responsibility Form

HIPPA Privacy Act


If you are from a physicians office and would like to make a referral for one of your patients to see Dr. Birchfield, you may download our Referral Form.  You can fax your completed form to us at (231) 347-1864.

Referral Form