All new patients must complete the New Patient Intake Packet prior to being scheduled. Additional forms can be completed online through the Patient Portal or you can print them from our website and bring them with you to your appointment. Please contact us if you have any questions regarding patient forms at 912-662-6501 and our team will be happy to assist you!
"Highly recommend DPS Health and Wellness. The providers and therapists are amazing and provide great care for their patients. The staff offers great customer service! Wanda R. and Casey D. are always so polite and helpful! Dr. Samuel's office has a friendly staff, a great atmosphere and caring providers! You cannot find a better office!"
Authorization for Release of Medical Information (PDF) - Allows patients to authorize the disclosure of their health information to a designated individual, company, agency, or facility. Autorización De HIPAA Para Divulgar Información Del Paciente
Authorization and Consent for Treatment (PDF) - All patients must provide their consent for treatment, communications (calls, emails, and text messaging), and agreement of financial responsibility. Autorización y Consentimiento Para el Tratamiento
Preferred Contacts (PDF) - Patients are encouraged to complete and return the Preferred Contacts Form but it is not required. Contactos Preferidos
Virtual Visit Policy (PDF) - This policy describes the process for the documentation, maintenance, and transmission of information using virtual visit technology.
Financial Policy (PDF) - This form advises patients of their complete financial responsibility for all medical services received without regard to insurance eligibility or coverage determinations. Política Financiera (PDF)
Notice of Privacy Practices (PDF) - Describes how health information about you (as a patient of this Care Center) may be used and disclosed, and how you can get access to your individually identifiable health information. Please review this notice carefully. Aviso de prácticas de privacidad (PDF)