Secure Document Upload
Please provide additional instructions and relevant clinical documentation.
Patient Information
Please provide pertinent contact and demographic information.
Patient Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Medication
*
Please Select
Treatment Documents
Please note that incomplete documentation will delay the treatment process.
Upload relevant lab/clinical and vaccine information.
*
Browse Files
Drag and drop files here
Choose a file
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Additional Instructions
Please include any known disability, including but not limited to physical, mental, or sensory impairments. Note this helps our intake coordinator prepare for reasonable accommodations during the intake process and treatment.
Please Select
None
Hearing Impairment
Visual Impairment
Cognitive Impairment
Physical Impairment
Other
Office Contact Information
Office Contact Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Fax Number
*
Please enter a valid phone number.
Work Email
*
example@example.com
Disclaimer
You will receive a confirmation email and downloadable copy for your records. Please note that a wet signature and faxed copy may be required depending on the patient’s insurance plan. If needed, a referral coordinator will contact you.
Agreement
*
I have read and understand the above statement.
Signature
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SUBMIT
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