New Patient Form

New Patient Form

Please complete the fields below. Those items with an *asterisk are required. Detailed forms are available in the drop-down menu on the right. Should you have any questions, please do not hesitate to contact our offices at the number and email address above.
Primary Email*
example@example.com
Patient's Legal Name*

First NameLast Name
Is the patient a minor?*
(Please see the Consent to Treat a Minor form in the drop-down menu on the right.)
If so, do you consent to the treatment of a minor?*

YesNo
Patient's Preferred Name*
Date of Birth*

MonthDayYear
Patient's Social Security Number*
Pronoun*
Please provide the pronoun to be addressed by.
Sex
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Primary Phone Number*
Please provide the primary phone number including the area code to contact the patient. EX: 319-626-3300
May we identify ourselves when calling?*

YesNo
Would you like to sign up for reminders?*

NoYes, Text RemindersYes, Voice Reminders
Marital Status(required)*
Emergency Contact*

First NameLast Name
Emergency Contact Phone Number*
Please Please provide the phone number(s) including the area code of whom we should reach out to with urgent information.

Insurance Information
Primary Insurance*
Subscriber ID*
Group Number*
Insurance Provider Phone Number*
This can usually be found on the back of the card.
Client's Employer*
Subscriber Name*
Relationship to Client*
Subscriber Address*

Street Address

Street Address Line 2

CityState

Zip Code
Do you have secondary insurance?

YesNo
Secondary Insurance
Subscriber ID (Secondary Insurance)
Group Number (Secondary Insurance)
Provider Phone (Secondary Insurance)
Is the patient also the Guarantor.

Yes. All information is the same. (Please skip to the HIPPA Policies)No. (Please complete all Guarantor questions.)
Guarantor Name (person responsible for billing)

First NameLast Name
Guarnantor's Social Security Number*
Guarantor's Relationship to Client
Guarantor Date of Birth

MonthDayYear
Guarantor Address

Street Address

Street Address Line 2

CityState

Zip Code
Guarantor Primary Phone Number*
This can usually be found on the back of the card.

HIPPA

Please see and review the HIPPA Notification of Privacy Policies in the drop down menu to the right.
Signature

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Insurance Information