Patient Forms

New Patient Forms

Welcome to the Westport Headache Institute! If you have any questions about how to complete these forms, please contact our office during business hours at (203) 391-6105.

• Westport Headache Institute New Patient Form – Please fill this form out two days prior to your appointment.
• COVID Screening Form – Our staff will call you the day prior to your appointment by phone to screen you for COVID-19. If we are unable to reach you, please fill this form the night before or morning of your appointment. For more information, please see our COVID-19 protocols.
• Notice of Privacy Practices (PDF)
• Office Communication Policy (PDF)

Other Forms

The following form is applicable to patients slated for a telemedicine appointment. This form can be signed electronically.

• Telemedicine Consent Form

Procedure Forms

The following forms are applicable to patients undergoing nerve blocks and BOTOX injections. These forms can be signed electronically.

• Therapeutic Botox Injection Consent Form
• Trigger Point Injection Consent Form
• Peripheral Nerve Block Consent Form

Other Forms

The following miscellaneous forms can be signed electronically.

• Release of Information – Please note that our fax number is 203-309-4395