Now accepting Telehealth appointments. Schedule a virtual visit.

Addiction


 

Hi from Rosenberg Medical Clinic,

Here are the intake forms we discussed. Click each link to be directed to the form. Once all are completed, please call our office to schedule an appointment (262) 242-0700. 

Looking forward to hearing from you.


  1. New patient information-   https://forms.myupdox.com/form/55470 
  2. Review of Systems-   https://forms.myupdox.com/form/73529
  3. Patient Health Questionnaire-    https://forms.myupdox.com/form/55468
  4. Buprenorphine Agreement-  https://forms.myupdox.com/form/73240
  5. Appointment Policy-   https://forms.myupdox.com/form/73388
  6. Pharmacy Consent-    https://forms.myupdox.com/form/73483
  7. Appointment Reminder Consent-   https://forms.myupdox.com/form/73771
  8. Consent for General Care and Treatment-   https://forms.myupdox.com/form/73522
  9. Patient Rights and Responsibilities-   https://forms.myupdox.com/form/73776
  10. Privacy Practices Acknowledgement-   https://forms.myupdox.com/form/73519
  11. Telehealth Service Consent-    https://forms.myupdox.com/form/73677
  12. Release of Information-    https://forms.myupdox.com/form/77285
Location
Rosenberg Medical Clinic
1516 W. Mequon Rd., 103
Mequon, WI 53092
Phone: 262-222-6827
Fax: 855-457-1293
Office Hours

Get in touch

262-222-6827