New Patient Enrollment Form Journey Healthcare

Full Name

First NameLast Name

Which Location are you seeking treatment at?

MurrysvilleRobinsonVirtual OnlyNo Preference

What type of treatment are you seeking?

Date of birth:

Date

What is your gender?

Contact Number

Email Address

example@example.com

Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Primary Insurance:

Member ID:

Are you currently active in treatment at Journey Healthcare?

YesNo

Please Select Current Symptoms

Substance Abuse History - Have you ever considered yourself to have a problem with alcohol or drugs?

YesNo

Please list substance use including substance type and frequency of use.

Do you have any medication allergies or known allergies?

YesNoNot Sure

Please list them.

Do you have any metal objects or implantable devices in or around the head (e.g., cardiac defibrillator/pacemaker, insulin pump).

YesNoUnsure

If yes, please list Medical objects.

Medical Diagnosis?

YesNo

If yes, specify medical diagnosis?

Recent surgeries?

YesNo

If yes, specify recent surgeries:

New Patient Enrollment Form