402-467-4545

Download paperwork

If you are coming to see us as a new patient, or are referring a patient to us for general consultation or dental or vision integrative services please download the appropriate forms below.  If you are a new patient bring your forms to your initial evaluation.  If you are referring a patient please fax the forms to us at 402-467-4580 or e-mail to us at contact@hruskaclinic.com.

Thank You!

If you have questions about any of the paperwork.  CONTACT US or ask the staff when you come to your initial visit.

FOR PROVIDERS

FOR PATIENTS

CONSULTATION PAPERWORK

If you are a PT referring a patient to the Hruska Clinic for a general consultation we would appreciate this information prior to our consultation time with your patient.

DENTAL TRIAGE PAPERWORK

If you are referring a patient to the Hruska Clinic for assitance with Dental Integration with a dentist please fill out this form prior to your patient coming to the Hruska Clinic.

VISION CONSULTATION PAPERWORK

If you are referring your patient to the Hruska Clinic for integration with our vision team we need this form filled out prior to the patient being scheduled with the vision team.

NEW PATIENT PAPERWORK

If you are coming to the Hruska Clinic as a new patient download our paperwork here.

PRIME APPLICATION

If you are interested in filling out our PRIME application for our in person multidisciplinary program or for online consultation download it here!

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