Patient Registration

Patient Registration

Prior to your consultation at Jelic Center, you need to complete our secure online Patient Registration Form.

Be sure to select Complete and Send  at the bottom right hand side at the end of the Patient Registration Form to email your completed form to us.

On your first visit to our office, we will have your completed Patient Registration Form ready for your signature.

The security and privacy of your personal data is one of our primary concerns.  We have taken every precaution to protect it.

If available, we request you bring to your consultation, a printed version of your “MY CHART” electronic medical record or the equivalent.

A treatment coordinator at Jelic Center will contact you 48 hours prior to your consultation to welcome you to Jelic Center.  They will verify your documents are complete and answer any questions you may have about your first visit.

HIPAA Notice & Acknowledgement

Click here to review our HIPAA notice

Keeping your safety in mind during the Covid pandemic we are using this GermAway UV product designed to reduce viruses, mold spores, yeast, and harmful bacteria such as C. diff and Strep that can exist in the air and specifically on hard surfaces. 

Questions? Get in touch with us today!

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