[Prod] Request an appointment v2

Submission Datetime

YearMonthDay
Hour MinutesAM/PM Option
Vita Email
example@example.com
Are you the patient?*

YesNo
What is your relationship to the patient?

Parent / legal guardianReferring party
Is the patient under 18 years of age?*

YesNo
Patient information
Patient legal name*

First NameLast Name
Patient preferred name
Patient current address*

Street Address

Street Address Line 2

CityState

Zip Code
Patient permanent address

Street Address

Street Address Line 2

CityState

Zip Code
Patient date of birth*

MonthDayYear
Patient phone number*
Patient email*
Patient preferred contact method*

TextPhoneEmail
Patient assigned sex at birth

FemaleMaleChoose not to discloseUnknown
Patient gender identity

Female/woman/girlMale/man/boyNonbinary, genderqueer, or not exclusively female or maleTransgender woman/trans woman/male-to-female (MTF)Transgender man/trans man/female-to-male (FTM)Prefer to self-describeRather not say
Patient pronouns

She/her/hersHe/him/hisThey/them/theirsOther
Patient race/ethnicity

American Indian or Alaska NativeAsianBlack or African AmericanHispanic or LatinoNative Hawaiian or Pacific IslanderWhiteOther
What issues are you facing?*

Feeling stressed or anxiousFeeling down or depressedHaving trouble focusing or with attentionStruggling with use of drugs or alcoholThoughts of harming selfOther
Preferred appointment times*
We'll use this information to find an open appointment slot.
Best times to contact you
We'll use this information to call you back, confirm your information, and book your appointment.
Preferred payment method

InsuranceSelf-pay
Insurance plan name
Insurance card picture

Please take a picture of the front and back of your health insurance card. We'll use this information to check what services are covered under your insurance plan before we schedule an appointment.

Please ensure that the text in the photo is clear. If the photo is blurry, it may cause a delay in scheduling your appointment.
Insurance holder name

First NameLast Name
Insurance holder date of birth

MonthDayYear
Emergency contact name

First NameLast Name
Emergency contact phone number
Please enter a valid phone number.
Emergency contact relationship to patient

ChildCousinFriendGuardianParentSiblingSpouseOther
How did you hear about Vita Health?

DoctorEmployerFriend or familyGoogleInsuranceSchoolOther
Doctor's name
Practice name
Practice location
School name
Employer name

Patient information

Parent / legal guardian information

Referring party information

Consent for Services