Patient Registration, Information & Forms

For your convenience, you may download and print the forms below and mail or fax them to us.

To view the forms, simply click on the name of the file to open it (Adobe Acrobat Reader 4.0 or above required). You will then have the opportunity to print the file if desired.

“This form may take approximately 30 minutes to complete. If you require more time please contact our clinic at 651-738-9888 to request that the Patient Registration and Intake form be mailed to you”.

• Patient Intake Form (CLICK HERE)
Click Here for Secure Online Patient Intake Form

• Patient Registration Form (CLICK HERE)
Click Here for Secure Patient Registration Form

• Patient Registration Signature Form (CLICK HERE)

• Patient Insurance Verification (CLICK HERE)

• Patient Service Agreement (CLICK HERE)

• Authorization to Release Information (CLICK HERE)

• Hippa Notice of Privacy Practices (CLICK HERE)

• Cancellation, No-Show, Tardiness Policy (CLICK HERE)



© Copyright 2019 - Family Achievement Center - Operated in the USA - All Rights Reserved

Non-Discrimination Disclosure | Privacy Policy | Terms of Service

Web Development Proudly Provided by: Scope 10 Inc. - A Minneapolis/St. Paul Digital Media, Marketing & Web Services Co.