Patient Forms

Susan K. Wynne, MDFor your initial appointment, please download, print and complete these forms.  Please bring the completed forms to your initial appointment.  If you do not have the paperwork completed for the initial appointment prior to the appointment, please arrive 20 minutes earlier than your scheduled appointment, in order to obtain and to complete this paperwork.

 

1. Please complete individual Release of Healthcare Information forms for:

 

  • a.) Primary Care Physician;
    b.) Psychotherapist;
    c.) Past Psychiatrist and/or Psychotherapist.
  • Download: Release of Healthcare Information - ( Word Document - 17KB)

 

2. Please read the Psychiatrist-Patient Services Agreement and sign and date it on the
     second page

 

 

3. Please complete the Patient Information form and sign and date it.  (Please note, there are two different forms,
     depending on if you are using Cigna insurance or if you are seeing Dr. Wynne as a Private Pay patient.)

 

4. Please complete the Medical Questionnaire form.