NC New Client Inquiry Form

1
Child's Name
First Name
Last Name
2
Child's Date of Birth
Date
Year
Month
Day
3
Parent's Name
4
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
5
Contact Number
Please enter a valid phone number.
6
E-mail
example@example.com
7
What services are you seeking for?* This field is required.
Physical Therapy
Occupational Therapy
Speech Therapy
Lactation
Feeding Therapy
Nutrition Consult
8
ACKNOWLEDGEMENT OF PRIVACY PRACTICESI understand that, under the Health Insurance Portability and Accountability Act of 996 (HIPAA), I have certain rights to privacy regarding my protected health information (PHI I understand that PHI can and will be used to (a) conduct, plan, and direct treatment of my child and follow-up among the health care providers who may be involved in that treatment directly and indirectly, (b) obtain payment for services, and (c) to conduct normal health care operations.I understand the privacy practices and understand that Nurture Collective has the right to change its policies and procedures, however I acknowledge that Nurture Collective will use and disclose my child's personal health information for treatment, payment, and other healthcare operations permitted by law. I understand that I may request a copy of the Notice of Privacy Practices to provide further detailed information about how we use and/or disclose protected medical information about your child for treatment, payment, healthcare operations, and as otherwise allowed by the law.I acknowledge that I have received the Notice of Privacy Practices (Notice The Notice describes, in accordance with the HIPAA Privacy Regulations, how Nurture Collective may use and disclose my child's protected health information to carry out treatment, payment or health care operations and for the other specific purposes that are permitted or required by law. The Notice also describes my rights and Nurture Collective's duties with respect to protected health information about my child.Signature Below
Clear
9
CONSENT FOR USE OF ELECTRONIC COMMUNICATIONI agree with the use of electronic communication, including electronic-mail, SMS, and voicemail delivery, in my interactions with Nurture Collective. I will not hold Nurture Collective for any tampering, interference, or unauthorized activity involving this electronic communication, and for information loss due to technical failures.Signature Below
Clear
10
You may upload an pertinent files (e.g. insurance cards, perscriptions, previous medical records) below.

* Please send a photo of the front and back of the insurance card.
11
File Type
Please Select
Please Select
Image
Video
Audio
Documents
Mixed
Others
12
Upload the photo of your insurance card here(Front&back)* This field is required.Note: Please make sure it's clear and readable.
Drag and drop files here
Select files to upload
Max. file size: 10.0MB
Cancelof
13
Upload the Doctor's prescription * This field is required.Note: We are unable to proceed without the Doctor's prescription.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
14
Any message?
Should be Empty: