New patients are required to complete the forms below:
We are currently accepting Aetna, Blue Cross Blue Shield PPO, and traditional Medicare.
We are not contracted with Cigna or Magellan. Dr Herzog is now accepting United Healthcare.
New patient appointments are for Evaluation and Medication Management, we do not schedule evaluations for FMLA, disability, Workers Compensation or Emotional Support Animal letters.
Please call and schedule your appointment before filling out forms
New Patient Packet
To be completed before the first visit.
Follow Up Packet
To be completed after the first visit.
- You cannot complete these forms more than 2 days in advance.
- These forms must be filled online and cannot be printed. When you arrive at your appointment, you can request a printed copy for your records.
- Please avoid closing your browser window until the final submission of the patient's data at the end. If you accidentally close your browser window, then you can come to our office to complete the forms.