New Patient Intake Forms

If you are a new patient, please download and complete one of the following pdf intake packets below.

Adult Intake Form Please fill this form out if you are a new adult patient. (Patients over the age of 14 years old).

Dr. Alicia’s Transfer Patients Adult Intake Form Patients who saw Dr. Alicia in her Origins Practice should fill out this intake form.

Pediatric Intake Form New patient intake form for children 0-14 years of age.

PAP – Gynecological Exam Intake Form For new patients who are having a female wellness exam.

Other Forms

Notice of Privacy Practices This Privacy Practices notification should be reviewed, but does not need to be printed or brought in with you to your appointment.

Expanded Adult Intake Form An expanded health interview for new adult patients, designed as a secondary, more thorough intake form.

Records Release Please fill out this form to release medical records from another facility to our office or to have our office release your records.

Records Release, for Origins Natural Medicine (Dr. Alicia’s practice) Origins patients who worked with Dr. Alicia McCubbins should sign this records release prior to their first appointment.

Referral Form Wanting to refer a patient to Prosper Natural Health? Please fill out this referral form and fax it to us.