Existing patient form
Patient name
First Name
Last Name
Preferred name (if different from legal name)
Preferred pronouns:
Patient Birthday
-
Month
-
Day
Year
Date
If the person completing this form is not the patient listed above, please provide you name and relation to the patient.
Which provider was the patient previously seeing?
Please Select
Dr. Bradley McClure, MD
Brenda Richards, PMHNP
Christine Dao, PA-C
Claire Roarty, PA-C
Stephanie Garrison, LCSW
Taylor Tope, PA-C
Patient Social Security number:
Patient Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email:
How do you prefer we communicate with you?
Please Select
Phone call
Text message
Email
Who is your insurance carrier? (ex: BCBS, Aetna, Soonercare). If you don’t have insurance, write self-pay.
Please list all current medications, including psychiatric and non-psychiatric prescription medications, as well as any supplements, vitamins, or over-the-counter medications you take on a regular basis. Please include the strength and directions (ex: Prozac 20 mg every morning. Olly Sleep Gummy every night as needed for sleep.)
What pharmacy would you like us to send medication to? (Please provide address).
Any medication, food, or environmental allergies? What type of allergic reaction do you have?
Please provide the name and number of your Primary Care Provider (write n/a if you don’t currently have one).
If you are currently seeing therapy, please provider their name and office name.
File Upload
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Please upload a picture of the FRONT SIDE of your insurance card.
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Please upload a picture of the BACK SIDE of your insurance card.
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