Forms

Simple, fast, and easy! As a new patient to Heelex, we would like to offer a warm welcome and our thanks for choosing us.

 

Save time before your next scheduled appointment. In order for us to establish your file, and provide the most beneficial use of your time with us, download the New Patient Forms below. Please return completed forms via mail, in-person, fax or email to office@heelex.net. We look forward to your visit! 

Patient Benefits

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Patient Demographics

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Patient Medical History

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First Visit

 

We encourage our new patients to bring in the following on the first visit to expedite the check-in process. If you are unable to download the paperwork, please arrive 10-15 minutes before the scheduled appointment.

 

  • All (3) Downloaded/Completed New Patient Forms

  • Insurance card(s).

  • Photo ID or Drivers License.

  • Medication List 

  • Dictation Imaging Records 

Referral Form

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Thank you for choosing to refer your patient to Heelex. To start the referral process, please complete this form and fax it directly to the clinic. Send brief, pertinent medical records, including test results and imaging, that support the consultation and a copy of the patient's insurance cards (both sides). For help referring a patient, please call us.We appreciate you! 

Convenience without Compromise. Save time by making an online appointment. Our clinic provides in-person or Telehealth consultation services with a provider for your convivence. Click the link below to get started today!