Forms

Note: We encourage new patients to view our FAQ page for answers to common questions.

Please complete and return the following intake and consent forms and other information outlined below within 1 week of the forms being sent (to hold your appointment time). You can send this information via email to mp4h@icloud.com (or fax it to 520-838-8682). If emailing, please send all forms and information outlined below as PDF files ONLY (please do not send pictures or JPEG files, for example).

• New Patient Evaluation Form
• Waiver of Liability
• Office Policy Waiver
• Medicare Agreement
• Consent to Release/Receive Confidential Information
• Arbitration Agreement
• MyPassion4Health HIPAA Compliance Policy
• Please provide a concise 1-2 page medical history or summary
• Please also send medical records, but limit to 20 pages or less. If Dr. Ackerley would like additional records, she will request them. This will streamline your telephone consultation with Dr. Ackerley.

(These documents are in pdf format and require Adobe Acrobat Reader in order to be viewed. If you do not have this program on your computer, click here to download a free copy from the Adobe web site)