New Patient Appointment Request Form
Thank you for your interest in becoming a patient of our practice. In order to determine if we are the best fit for you, we need to ask you a few questions prior to you booking your first appointment with our office. Please answer all questions, and a member of our office will get back to you and discuss whether or not we are able to accommodate your needs. Requesting an appointment using this form does not establish a provider/patient relationship.
Name:
*
First
Last
Date of Birth:
*
-
Month
-
Day
Year
Sex:
*
Please Select
Female
Male
Assigned at birth
Photo Identification:
*
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Drag and drop files here
Choose a file
Please attach a picture of the front and back of your driver's license or alternative photo identification card
Cancel
of
Phone Number:
*
Please enter a valid phone number
Email Address:
*
example@example.com
Preferred Contact Method:
*
Please Select
Call
Text
Email
Any
Home Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Name:
*
First Name
Last Name
Emergency Contact Number:
*
Please enter a valid phone number.
Do you currently have insurance? If yes, please attach a picture of the front and back of your card below. Please reach out to our office with any questions or for assistance.
*
Please Select
Yes
No
Browse
Drag and drop files here
Choose a file
If you currently have insurance, please attach a picture of the front and back of your card
Cancel
of
Past and Current Primary Care Providers and Specialists:
*
PCP, OB/GYN, eye doctor, dentist, etc.
Past and Current Diagnoses:
*
Medical and/or psychiatric or none
Past and Current Medications (name, dose, & how taken):
*
Prescription and over-the-counter or none
Controlled substances, such as Adderall, Xanax, Ambien, and others, are prescribed at the provider's discretion and are not guaranteed. If taking these medications, are you willing to try an alternative medication or taper off of your current medication?
*
Please Select
Yes
No
N/A - I do not take these medications
What is your reason for requesting services?
*
Please Select
Establish care
New issues
Disability evaluation
Legal issue
Other
Thank you for your interest!
We will be in touch soon if we are able to assist you.
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