Patient Forms

Please download the Intake Form, and review thoroughly as it contains important information about Shifa Therapeutics professional services, and business policies.

Completed forms should be returned to Shifa Therapeutics electronically or in person:

• E-mail the completed form to adminstaff@shifatherapeuticsllc.com, ATTN: Intake Specialist - patient name in the subject line.

• Bring the completed form with you on the day of your appointment.

Please download the Release of Information Form which allows for the release/authorization of various patient account information to an entity or individual of choice designated by the patient, parent, or guardian. The patient, parent or guardian can choose the type of information that is to be released/authorized from the account as well as indicate the effective start and end date of the release/authorization.

Patients 18 years of age and older should complete and submit a release/authorization form if they wish to grant another individual(s) access to their account information.

Completed forms should be returned to Shifa Therapeutics electronically or in person:

• E-mail the completed form to adminstaff@shifatherapeuticsllc.com, RE: ROI - patient name in the subject line.

• Bring the completed form with you on the day of your appointment.