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Intake forms

Please download and complete one of the packets below and either email it to drpamluttig@gmail.com or mail it to 114 Hawthorn Court, Lake Frederick, Virginia, 22630 before your first appointment. 

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Please read each section carefully and sign where indicated. Feel free to contact me if you have questions or concerns. Complete only one packet based on the primary patient's information.  

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Child & Adolescent Patient Intake Packet 

To be completed by parent[s]. The Informed Consent Agreement must be signed by both parents or legal guardians.

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Adult Patient Intake Packet

To be completed by adult patient (18 years +)

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Download just the release form. (PDF)

 

If you are uninsured, you have a right to a good faith estimate of the costs of medical services. (PDF)

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