PATIENT FORMS & POLICIES
To access any of our forms, please click on the "Download File" link.
Once opened, you can complete the forms online.
We do ask that you complete all forms in blue or black ink only. Thank you
New Patient Packet (Non-Headache)
Complete this packet if you are coming to Piercey Neurology as a new patient.
New Patient Packet (Migraine/Headache)
Complete this packet if you are coming to Piercey Neurology as a new patient for Migraine or Headache.
New Patient Packet (Parkinson's)
Complete this packet if you are coming to Piercey Neurology for the first time, and have been diagnosed with Parkinson's.
New Patient EMG Packet
Complete this packet if you are coming to Piercey Neurology as a new patient for EMG or NCS.
Memory Test Packet
If you are coming in for a neurocognitive test, please complete these forms and bring them with you on the day of your appointment.
PN Medical Marijuana Position & PN Controlled Medication Agreement
Prepare for your visit by completing this optional information sheet!
Piercey Neurology Privacy Practices:
Once the new patient forms are completed, please feel free to send them back to us prior to your appointment. If your appointment is more than a week away, you may mail them. However, if you are scheduled to come in within a week, please bring them with you to your appointment. You may also fax them. You will also notice some forms require a signature or initials, these forms can be signed in the office on the day of your visit. Thank you, and we look forward to seeing you!!
To submit via fax, send to: 541-207-3232
**Email and HIPPA :) Please note the Health Insurance Portability and Accountability Act of 1996 (HIPAA) places a number of requirements on the healthcare industry’s information handling practices, and has a number of direct impacts on the operation of messaging systems. This means that email is not HIPPA compliant. At PIERCEY NEUROLOGY LLC we take every precaution to protect your information. This means that if you send us information via email we cannot assure privacy. If the information you wish to communicate is private then please use Fax, Mail or hand deliver it to our office.