Before your first appointment with Dr. DeRight, please download, print, and complete this questionnaire. It will provide Dr. DeRight with useful clinical and historical information, and will assist him in evaluating your symptoms and making recommendations for treatment planning. Bring the completed form, your insurance card, and form of payment, along with your completed New Client Registration forms, to your first appointment.
Do not use this form in an attempt to schedule an appointment. Again, please submit this form only after you have already scheduled an appointment with one of our Providers. Forms submitted without a scheduled appointment will not be reviewed, and you will not be otherwise contacted.
All health and health-related information contained within this WPAPC website is intended to be general in nature and should not be used as a substitute for a visit with a health care professional. No information provided in this site may be considered medical advice. The information may not be relevant for your individual situation and may be misinterpreted. WPAPC assumes no responsibility for how you use information obtained from this site. Before making any decisions regarding your health care, ask your personal physician.
Please be aware that most information transmitted over the Internet is not secure; thus, confidentiality cannot be guaranteed. Information of a confidential, proprietary or privileged nature should not be sent electronically to WPAPC. Any patient information transmitted to our site will be treated as non-confidential. Personal medical information should never be sent to our website.