Forms Posted by Clemmons Neuropathy Specialist August 19th, 2021


Complete your New Patient Forms prior to your initial visit by printing the registration form along with the evaluation form and bring them to your first appointment.

You can also submit your form directly on our website by following the steps below:

PDF Submission


Fill out the

New Patient
Information Form


Save your form to your computer


Attach it to the submission box to the right and send

Online Portal

Follow this link to submit
via our portal

New Patient
Information Form

Billing and Insurance

We hope you understand that our credit and collection policies are a necessary part of assuring the financial resources necessary to maintain a vital and current environment to treat our patients. Please remember that payment of fees is your direct responsibility regardless of your insurance coverage.

Charges or Co-Payments are due at the time services are rendered.

We accept cash and personal checks.
If unusual circumstances should arise that make it impossible to meet your financial obligation, we will be happy to assist you in making arrangements for agreeable payment plans.

Medicare and most insurance policies are accepted and will be filed for you. For specific Insurance coverage, please call.