Call Us: (406) 755-1113

Visit Us: 248 - 3rd Avenue East, Kalispell MT 59901
Schedule your own appointment

Forms

New Patient Forms

Demographics Form History Form Intake Form Financial Policy Privacy Policy Health Status Questionnaire
For new patients never seen before in this office:  please download & print each of the forms above and complete them prior to your appointment to save time.  The more complete they are - the better Dr. Purdy can serve you.

 If you have any of the specific situations listed below please print those below here only as needed.
Medicare your insurance carrier? Use this form CDL Exam Car Accident? Use this form Worker's Comp 1st Injury Report Need a sports exam for school? Use this form

Returning Patient Forms

New Injury? Use this form New address? or New insurance? use this form Motor Vehicle Accident? Use this form Have you had a new injury at work? Use this form Need a sports exam for school? Use this form
Is cost a concern for you?  Please be assured Dr. Purdy is NOT going to put you on a long treatment plan and will not recommend more care than what you need to accomplish YOUR goals.  If money is the only thing preventing you from getting the care you need please ask about our sliding fee program designed to help those who really do not qualify for other programs or for those without insurance coverage or very high deductibles.   The form below along with proof of income for the HOUSEHOLD should be brought with you to your appointment so we can determine where you fit in the sliding fee scale.  We consider incomes up to 195% of the federal poverty guidelines as eligible for reduced fees.
Financial Disclosure
Share by: