Client Forms

Please complete forms online and submit or you can download, print and fill out the following and email it to imiolaclinic@gmail.com *Please include your reason for coming in as well in the email*

NEW CLIENT

Patient Registration Form

Patient Communication Form

Imi Ola Patient and Payment Policy

HIPAA FOrms

HIPAA POLICY Clinic
HIPAA ACKNOWLEDGMENT
HIPPA RELEASE OF INFORMATION FORM
HIPPA Notice of Privary Practice

IMPORTANT INFORMATION

If you plan to utilize your insurance, please attach:

A front and back photo of your medical insurance card
A front and back photo of your picture ID (Driver’s License, State ID, Etc.)

Please indicate via email if you are preferring in-person or telehealth sessions. Once completed, please email the completed forms and items to info@imiolaclinic.com

Client Forms

Client Forms

NEW CLIENT

HIPAA FOrms

IMPORTANT INFORMATION

'Imi Ola Health & Wellness Clinic