The VIOS Clinic Membership Application

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We’d like to welcome you as a new patient! Please take the time to fill out this form as accurately as possible so we can give you the best service.

The confidentiality of your health information is protected in accordance with federal protections for the privacy of health information under the Health Insurance Portability and Accountability Act (HIPAA). This form is encrypted and secured by Google for the collection and storage of ePHI (electronic personal health information). You will be entered into our weekly newsletter mailing list, you may unsubscribe at any time.

Email *

Name of Patient *

(Legal Full Name)

Are you completing this form for yourself or on behalf of someone else? *

For me

For someone else

Are you 18yrs or older? *

Yes

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