Shore To Shore New Patient Registration Form

Please Fill Out Completely and Press the "Submit" Button at the End of the Form. We will call you within 24 hours to coordinate your first visit.

Date & Time Form Filled Out*

MonthDayYearHourMinutesAM/PM Option

Name*

First NameLast Name

Date of Birth*

Date

Social Security Number:*

Administrative Sex(At Birth)*

MaleFemale

Identify as(if other than Administrative Sex)

Height(Feet, Inches)*

Weight(Pounds)*

Phone Number*

Email*

example@example.com

Marital Status*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Employment/Schooling Status*

In Case of Emergency, Please fill out the Following Information:

Emergency Contact Name

First NameLast Name

Relation to Patient

Phone Number

Area CodePhone Number

Reason for Registering as a Patient:

Services Requested*

Medication ManagementTalk TherapySuboxone Maintenance/Addiction TreatmentEsketamine/Ketamine Treatment

Primary Reason For Visit:*

ex. Feeling Sad Often; Anxiety & Panic Attacks.

Are you currently on any prescribed medications?*

YesNo

If you answered yes, list them here(Dosage, method of consumption, approximate time on medication)::

Please list your preferred pharmacy(Name, Address & Phone Number):*

If you currently and/or recently were seeing a Psychiatrist or Therapist, please list them here(Name, Address, Phone Number):

If you see any other doctors, please list them here (Name, Address, Phone Number)

Please list any Medical Conditions:

Please list any Surgical History:

Do you have any allergies to medications? Please list them below:*

Breif Psychiatric History:

Have you ever attempted suicide?*

YesNo

Do you have access to a firearm?*

YesNo

Do you use illicit drugs or abuse prescription medication?*

YesNo

If you answered yes, please list all substances below:

Have you ever been psychiatrically hospitalized?*

YesNo

If you answered yes, please list the approximate or exact dates and hospitals admitted to:

Do you have any current legal issues? If so, please list them:*

Method of Payment*

Private PayMedical Insurance - Check with our office to see if we are accepting your insurance plan yet.

The Private Pay Rates are as follows:

$150; Evaluation/Intake Visit(1st visit).

$100; Follow Up Visits(every follow-up visit).

$200; Suboxone Maintenane - initial and follow up visits.

$625/Month(Paid at the beginning of each month); 1st month of Ketamine/Esketamine treatment. Includes medication, evaluation and two treatment visits per week.

$525/Month(Paid at the beginning of each month); Ketamine/Esketamine Treatments; Includes Medication and one visit/week every month thereafter(4 Total Visits/Month).

Name of Primary Policy Holder:*

Relationship to Patient:*

Primary Policy Holder's Date of Birth*

Primary Policy Holder's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Medical Insurance Plan/Network:*

Member ID:*

Group Number(if known)*

Amount of Specialist Copay(if known)*

The Next Portion of the Registration Form Requires You to Take Pictures of Your Medical Insurance Card.

Take a photo of the front of your Medical Insurance Card*

Take a photo of the back of your Medical Insurance Card*

The Next Portion of the Registration Form Requires You to Take Pictures of Your Identification Card.

State ID/Driver's License(front)*

Picture ID/Driver's License(back)*

Review Practice Policy and Acknowledge by Signing Below:

Emergencies

In addition to our regular office hours, our practie has coverage 24 hours a day / 7 days a week coverage. Within a reasonable time frame, We will respond to any text, email, or voicemail. We can make time for any patient emergencies and want to be available to help you. Our hours of Preferred call time is 9am-9pm on weekdays.

Office Visit Policy

All Patients will be required to present a driver's licences or photo ID, and payment will be collected at every office visit prior to being seen by your provider. If payment if not made, you will not be able to be seen, and will have to reschedule.

Refill Policy

Please understand we will honor all refill request via email or telephone in 48 hours, so please be aware that you will need to call 7 days prior to your running out of your medication to obtain this quick response. Otherwise the expectation is to see your provider on the next or same business day in the office by scheduling an appointment to obtain a refill, and this may be by another covering physician.

Payment Policy

Payment is due at the time of service. If you cannot pay for your visit, your visit will be resceduled. Based on your choice of payment, as related to your annual income, you may be asked to provide proof(i.e pay stubs) of income status.

Cancellation Policy

Please call at least 24 hours before your office visit to cancel your appointment. If you are rescheduling an appointment, please let us know so that we can cancel it and open the time for another patient. You will be assessed a missed appointment fee of $50.00 if you cancel on the same day as your appointment, or miss an appointment completely. Also please keep in mind that 3 consecutive cancellations will be considered as noncompliance as well as 2 or more no shows, and this constitutes grounds for termination of treatment. Once discharged or terminated from practice you will not be accepted back.

Signature*

Sign in this box using your mouse to the best of your ability

Patient Consent/Contract for Treatment with Shore 2 Shore Psychiatry & it's business associates:

As a participant in treatment for medications and/ or therapy, I freely and voluntarily agree to accept this treatment contract as follows:

1. I agree to keep and be on time to all my scheduled appointments.

2. I agree to adhere to the payment policy outlined by this office. Payments must be made via cash, credit card or certified check or cashier check. Personal checks are NOT acceptable.

3. I agree to conduct myself in courteous manner in the office as well as on the property grounds.

4. I agree not to sell, share, or give any of my medication to another person. I understand that such mishandling of my medication is a serious violation of this agreement and would result in my treatment being terminated without any recourse for appeal.

5. I agree not to deal, steal, or conduct any illegal or disruptive activites in the doctor's office.

6. I understand that if dealing or stealing or if any illegal or disruptive activities are observed or suspected by employees of the pharmacy where my medications are filled, that the behavior will be reported to my doctor's office and could result in my treatment being terminated without recourse for appeal.

7. I agree that my medication/prescription can only be given to me at my regular office visits. A missed visit may result in my not being able to get my medication/prescription until the next scheduled visit.

8. I agree that the medication I receive is my responsibility and I agree to keep it in a safe, secure place. I agree that lost medication will not be replaced regardless of why it was lost.

9.I agree not to obtain medications from any doctors, dentists, pharmacies, or other sources without telling my treating physician.

10.I will let my physician know of all medications that I am being currently prescribed including those given by other treatment providers.

11. I agree to take my medication as my doctor has instructed and not to alter the way i take my medication without first consulting my doctor.

12. I understand that medication alone is not sufficient treatment for my condition, and I agree to participate in counseling as discussed and agreed upon with my doctor and specified in my treatment plan.

13. I agree to abstain from alcohol, opioid, cocaine, and other addictive substances(except nicotine), unless necessary for a medical condition.

14. I agree to provide random urine samples or testing( if requested) and have my doctor test my blood alcohol level.

15. If there is a problem and the patient cannot make the scheduled appointment please call the office and leave a message. Failire to contact the office and not showing up at the scheduled appointment may result in a $50.00 fee that will be assessed at the following visit.

16. We do not take any responsibility for any failure of insurance reimbursements. You will be billed for any balances you are responsible for *Sublocade treatment & Esketamine treaments is a service that is very difficult to be reimbursed from insurance, and as such Sublocade, Suboxone & Esketamine are private pay only.

17. You must let your provider or the staff know of any changes in your insurance policy, otherwise you will be responsible for the charges incurred.

18. If you have not been compliant with your treatment visits for a period of 90 days, your case will be considered closed/inactive and be terminated from treatment of which we will send you a notification on the 90th day.

Signature*

Welcome to Shore To Shore Psychiatry, an affiliate of PsychMD Healthcare Management! We look forward to partnering with you in your growth while being with the practice.

At your first visit, you will be required to check-in, take a urine toxicology test, fill out 3, single-page questionairres, and make payment for services.

New Patient Registration

Medical Insurance - Primary