New Patient intake form

Name*

First NameMiddle NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.

Date Of Birth*

Date

Today's Date*

Date

Age*

Email *

example@example.com

OK to Leave Message/Text:*

YesNo

Emergency Contact / Relationship

Area CodePhone Number

Upload your image

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Upload your insurance card front side image

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Upload your insurance card back side image

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Primary Insurance*

ID#*

Primary Subscriber:*

Primary Subscriber Date of Birth:

Date

Secondary Insurance

ID#

Pharmacy*

Referred by (PCP/ Therapist/ Online)*

Reason For Visit*

Are you interested in TMS(Transcranial magnetic stimulation) therapy*

YesNoI am interested in finding out more about TMS

Current Medications/Supplements (Dosages / Start Date)*

Mental Health Treatment History (Psychiatrist, Therapist, Inpatient, Outpatient, Detox, Rehab):*

Previous Medication Trials(Dosages/ Dates):*

Medical Conditions(Seizures, BP, Diabetes, etc.)*

Current Healthcare Providers (PCP, Specialists, etc.)

Social History (Work, Living Situation, etc.)*

Upload Related Medical Documents (PCP Visit Summary, D/C Papers, Pharmacy Rx Printout, etc.)

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Our intake coordinator will reach out to you within 24 hours.

Once your appointment is scheduled, you will receive a link to our Advanced MD Patient Portal to fill out the required patient forms. If you are not able to fill out your forms, please come to the office 30-45 minutes earlier to complete the forms.

What to bring with you to your appointment:

1) Insurance Cards

2) Photo ID

3) Current medication bottles OR printout from the pharmacy

There is a missed appointment of $50 if you cancel within 24 hours of your appointment time.

The first appointment is for evaluation and it is not a guarantee of ongoing care or medications.

New Patient intake form

Insurance

OR

MENTAL HEALTH HISTORY

MEDICAL HISTORY

WHAT IS NEXT?