144 US Route 1, Scarborough, ME 04074
P: (207) 415-4841
F: (888) 612-5691

Registration Forms

Thank you for allowing us to participate in your care. To make your first visit go as smoothly as possible, please review and collect the following information to prepare prior to your visit:

  • Patient Intake Form
  • HIPAA Policy
  • Financial Policy
  • Your insurance card or insurance information (including policy number)
  • Any x-rays, scans or pertinent lab work you have had for the condition for which you are seeing us (if possible, please bring the CD/DVD images and not just the paper report)
  • Any pertinent medical records from your current physician
  • The names of all of your current medications
  • Your primary care physician referral form, if appropriate
  • Incoming Consult Referral Form

© Benjamin Liess, MD, FACS