Please note: Dr. Klausner uses a file sharing portal for secure electronic communication. After downloading and filling out the forms needed for your appointment, please call Dr. Klausner’s office to be set up on the file sharing portal or print forms and bring them to the office.
If you are a new patient, you will be set up on the portal when you schedule your first appointment.
All the forms are fillable PDFs, and by filling in your name electronically on the forms, you are agreeing that your electronic signature is the legal equivalent of your manual signature.
Prior to your first appointment, new patient forms must be filled out and returned to our office seven days prior to your appointment. If we do not receive the forms within this time frame, your appointment may be cancelled and rescheduled at a later date.
Authorization for Email Communication
Email Consent (Please initial all lines and sign at the bottom of second page)
All new patients must complete the following five forms.
New Patient Registration Form
Patient Representative Release Authorization
Informed consent no Medicare coverage
Patient Medical Biography
Established Patients Follow Up Appointments
The completed form must be sent through Dr. Klausner’s file sharing portal 4 days prior to your next visit. Contact Dr. Klausner’s office to be set up on the portal, if you have not already done so.
Medical Information Release
For Dr. Klausner to obtain medical records from and or release records to another doctor, please fill out the following form which applies.
Medical Records Release Form to Dr. Klausner
Medical Records Release Form from Dr. Klausner
Lyme Disease Forms
Below you will find our Lyme Disease patient forms. Please click links to download and fill out the forms you need. All patients currently being treated by Dr. Klausner for Lyme need to fill out the Lyme preappointment patient update form and return to Dr. Klausner at least 3 days before each in person or telephone appointment.
MSIDS Horowitz/MSIDS Lyme Questionnaire
Informed Consent for Lyme
Lyme Consent for treatment
Lyme Progress Notes
C. difficile Patient Acknowledgement