New Patient Registration & Health History Form
Thank you for taking the time to complete this form. Sharing your medical history with us will provide vital information needed for the delivery of high quality and personalized care that you deserve.
This form must be completed prior to arriving for your appointment. If you do not have a scheduled appointment with us, do not complete this form.
In order to prevent an appointment delay or cancellation, please take the time to complete the entire form in the comfort of your home.
If you need to take a break, you may scroll to the bottom of the page and click the Save & Continue Later button, and enter your email address. We look forward to our journey with you.
While CCBD will use reasonable administrative and technical safeguards when transmitting your electronic PHI in accordance with applicable law, we also realize that there are inherent risks when communicating via email. Therefore, please be aware that by choosing to send your protected health information (PHI) and related communications via email, you are agreeing to accept the risk that your PHI may be intercepted or viewed by persons with access to your email who may not be authorized to receive such information when you consent to communication through email. CCBD will not be responsible for any privacy or security breaches outside of its control that may occur through email communications that you have consented to.