For your convenience, we have supplied our general patient forms below.  If you wish, click on the links below, print, complete the forms, and bring them with you to your appointment.  Printing them, filling them out and bringing them with you will allow us to attend to your medical needs more quickly than completing them upon your arrival.

 

NEW PATIENT INTAKE PACKAGE:

REGISTRATION FORM:  CLICK HERE

NOTICE OF PRIVACY PRACTICES (HIPAA):  CLICK HERE

PATIENT INFORMATION DISCLOSURE FORM:  CLICK HERE

PATIENT QUESTIONNAIRE - ENGLISH:   CLICK HERE

PATIENT QUESTIONNAIRE - ESPANOL:  CLICK HERE

 

OTHER FORMS:

PATIENT BILL OF RIGHTS: CLICK HERE

MEDICAL RECORD RELEASE FORM:  CLICK HERE

PATIENT COMPLAINT FORM: CLICK HERE
 

If, for some reason, you felt that the service you received was not satisfactory, please fill out our Patient Complaint Form online and email it to Scott Gretz (sgretz@whcccc.org) with the subject line "Patient Complaint." You can also call Scott to discuss your experience at 203.852.9525. If you prefer to mail the Patient Complaint Form, please download it and send it to:

CIRCLE CARE Center
c/o Scott Gretz
618 West Avenue
Norwalk, CT 06850