Patient Registration

We are now a paperless office and you may preregister with our office by filling out our secure encrypted online Patient Registration Form to decrease your wait time before seeing Dr. Couchot. After you have completed the form, please make sure to press the Submit button at the bottom to automatically send us your information. On your first visit to our office, we will have your completed form available for your signature. The security and privacy of your personal data is one of our primary concerns and we have taken every precaution to protect it.

Patient Registration Form