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New Patient Forms
Required before first appointment
DO NOT EMAIL CREDIT CARD INFORMATION

ADULT
INTAKE

FINANCIAL

RESPONSIBILITIES

PEDIATRIC
INTAKE

FINANCIAL

RESPONSIBILITY

PAGE 2

INSURANCE
FORM
HIPAA Form
& CONTACT

OFFICE HOURS

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Monday 8:00 – 5:00
Tuesday 8:00 – 5:00
Wednesday 8:00 - 1:00
Thursday 8:00 – 5:00
Friday 8:00 – 1:00

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Natura Medica

frontdesk@naturamedicamystic.com
12 Roosevelt Avenue
Mystic, CT 06355

Phone:860-572-9566
Fax: 860-572-7318

Information

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Additional Forms and Information

Release of Medical Records
Patient Payment Plan
Annual Comprehensive
Wellness Visit Form
HIPAA: Privacy Practices Pg1
(information purposes only)
HIPAA: Privacy Practices Pg2
(information purposes only)

© 2016 -2021 Natura Medica Mystic, CT

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