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Patient Forms
FOR NEW PATIENTS:
If you have a new patient appointment with Dr. Jung at Northlake Neurology, please download
and print these new patient forms. Once completed, please fax them to 704-316-1848 or mail
them to: Northlake Neurology, 16525 Holly Crest Lane, Suite 120, Huntersville, NC 28078.
These forms will need to be faxed or mailed to our office PRIOR TO your appointment.
If your appointment is within the next 2 days, please complete the forms and bring them with
you to your appointment, as that they will not arrive on time if you mail them.
Welcome Letter
Patient Information/Consent to Treat
Notice to Our Patients
Medical History Form
Financial Policy
Managed Care Waiver
New Patient Question Sheet
FOR EXISTING PATIENTS:
If you are an existing patient of Dr. Jung's before his transition over to Presbyterian Novant
Medical Group, you will need to download, print, and complete the Authorization to Release
Health Information. This release for your medical records is necessary for the continuity of your
care with Dr. Jung, as that your medical records will need to be requested from Dr. Jung's
former practice affiliation. Please complete the release and return it to our office via fax at
704-316-1848 or mail it to: Northlake Neurology, 16525 Holly Crest Lane, Suite 120, Huntersville, NC
28078.
Thank you for your time and cooperation!
FOR NEW PATIENTS:
If you have a new patient appointment with Dr. Jung at Northlake Neurology, please download
and print these new patient forms. Once completed, please fax them to 704-316-1848 or mail
them to: Northlake Neurology, 16525 Holly Crest Lane, Suite 120, Huntersville, NC 28078.
These forms will need to be faxed or mailed to our office PRIOR TO your appointment.
If your appointment is within the next 2 days, please complete the forms and bring them with
you to your appointment, as that they will not arrive on time if you mail them.
Welcome Letter
Patient Information/Consent to Treat
Notice to Our Patients
Medical History Form
Financial Policy
Managed Care Waiver
New Patient Question Sheet
FOR EXISTING PATIENTS:
If you are an existing patient of Dr. Jung's before his transition over to Presbyterian Novant
Medical Group, you will need to download, print, and complete the Authorization to Release
Health Information. This release for your medical records is necessary for the continuity of your
care with Dr. Jung, as that your medical records will need to be requested from Dr. Jung's
former practice affiliation. Please complete the release and return it to our office via fax at
704-316-1848 or mail it to: Northlake Neurology, 16525 Holly Crest Lane, Suite 120, Huntersville, NC
28078.
Thank you for your time and cooperation!
| Copyright 2006-2011 Northlake Neurology. All rights reserved. |