Online Forms / Formularios

CALL / LLAME (305) 371-5775

Synergy Wellness Clinic offers our patient forms online so they can be completed in the convenience of your own home or office and to reduce your wait time when coming in for the first time.

• If you do not already have AdobeReader® installed on your computer, Click Here to download.
• Download the necessary form(s), print it out and fill in the required information.
• Fax us your printed and completed form(s) or bring it with you to your appointment.

New Patient Health History Form - Required

This lets us know the history and current state of your health. What questions, concerns, goals, regarding wellness can we help you with? Let us know! All patients must fill this out.

Patient & Insurance Information

In this form you supply us with your address, phone numbers, and insurance. All patients must fill this out.

Download & Print Form

HIPPA Notice of Privacy of Personal Health Information (PHI)

Your PHI is protected by federal law. This form explains your legal rights. All patients must fill this out.

Download & Print Form

Informed Consent

This form explains the risks and benefits of treatment and your signature gives us permission to provide you treatment. All patients must fill this out.

Download & Print Form

Doctors Lien

This form is only utilized for personal injury cases when you do not have any insurance to subsidize your care and whereby you accept financial responsibility and instruct your attorney and third party payers (during settlement) to pay SWC for the services we will render to you. If the previously described scenario does not describe your reason for coming to us do not fill it out.

Download & Print Form

Assignment of Benefits

This form is utilized when you have insurance to subsidize your care and either you were involved in a motor vehicle accident or we are out of network with your insurance company. In this form you instruct your insurance company that you are assigning your benefits to SWC for the services we will render to you. If the previously described scenario does not describe your reason for coming to us do not fill it out.

Download & Print Form

Personal Injury Forms

These forms are to be filled out if you are coming to us for treatment due to an injury, such as a motor vehicle accident, slip and fall, assault, battery, etc. 

Download & Print Form

Member Wellness Registration Form - Optional

This form can be filled out to register for access to the member wellness section of our website. You can also sign up for our monthly newsletter to keep up on current health issues and news and events in our office. You can print it out and bring it in to our office or Click Here to register online! The online newsletter sign-up is also on the right. We look forward to making your experience with our office and website more interactive and rewarding!