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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 704-660-0091 or mail
them to: Northlake Neurology, 157 Professional Park Drive, Suite B, Mooresville, NC 28117.
These forms will need to be faxed or mailed to our office PRIOR TO you 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
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 704-660-0091 or mail
them to: Northlake Neurology, 157 Professional Park Drive, Suite B, Mooresville, NC 28117.
These forms will need to be faxed or mailed to our office PRIOR TO you 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
704-660-0091 or mail it to: Northlake Neurology, 157 Professional Park Drive, Suite B,
Mooresville, NC 28117.
Thank you for your time and cooperation!
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
704-660-0091 or mail it to: Northlake Neurology, 157 Professional Park Drive, Suite B,
Mooresville, NC 28117.
Thank you for your time and cooperation!
| Copyright 2006-2009 Northlake Neurology. All rights reserved. |