Spravato Investigation Form
Patient Name
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
Address
City
State
ZIP
Is the practice authorized to leave detailed voicemails on the number provided above?
Yes
No
Employer
Gender Identity
Male/Man
Female/Woman
Trans Male/Trans Man
Trans Female/Trans Woman
Gender Queer/Gender Non-Conforming
Something Else
Decline to Answer
Other
Sexual Orientation
Straight
Gay
Lesbian
Bisexual
Queer
Other
Decline to Answer
Significant Other Status
Single
Married
Partnered
Divorced
Widowed
Referring Psychiatrist/Psychiatric Nurse Practitioner
Billing address (if different from above)
Same as above
Address
Street Address Line 2
CITY: STATE: ZIP CODE
State / Province
Postal / Zip Code
City
State
ZIP
Insurance #1
Effective Date
/
Month
/
Day
Year
Date
Policy #
Group
Policy Holder
Relationship to Patient
Holder DOB
-
Month
-
Day
Year
Insurance #2
Effective Date
/
Month
/
Day
Year
Date
Policy #
Group
Policy Holder
Relationship to Patient
Holder DOB
-
Month
-
Day
Year
Pharmacy Insurance Information
Contract #
BIN
PCN
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