AIMS Request an Appointment Form

Request an Appointment

Complete the form and a team member will call you within the next business day.
Demographic Information
Name*

First NameLast Name
Phone Number*
Format: (000) 000-0000.
E-mail*
example@example.com
I'm referring an individual to the AIMS program, or I have been referred to the AIMS program by another provider:

YesNo
Referral Source
Referral Organization:
Name of Referral:

First NameLast Name
Referral Source Email
example@example.com
Referral Source Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Best way to reach you
Type of Service Requested:

Buprenorphine (Suboxone)Long-acting injectable Buprenorphine (Sublocade/Brixadi)Naltrexone (ReVia)Long-acting injectable Naltrexone (Vivitrol)CRS/Peer ServicesOther
Do you have a previously diagnosed substance use disorder?

YesNo
Select SUD diagnosis:

Opioid Use DisorderAlcohol Use DisorderOther Use Disorder
If other specify
Priority Population/Specialty Population (select any that apply)

Pregnant injection drug userPregnant substance userGiven birth within the past 28 days.VeteranInjection drug userOverdose survivor
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
Gender
Race
Race Other:
Ethnicity
Ethnicity Other:
Last Four of SSN:
Smoking Status
Preferred Language
Funding Information
Type of Funding

MedicaidCommercialUninsuredOther
What County do you reside in?

AlleghenyWestmorelandOther
Marital Status

SingleMarried
How many individuals live in your house?
Total number of dependents

Calculation
Primary Insurance:
If available
Member ID:
If available
Secondary Insurance:
If Applicable
Member ID:
If available
Emergency Contact
Emergency Contact Name

First NameLast Name
Relationship:
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Email
example@example.com
Pharmacy
Pharmacy Name
Pharmacy Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Pharmacy Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
PCP
Primary Care Physician

First NameLast Name
PCP Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PCP Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Date last seen

MonthDayYear
Date
Are you pregnant?

YesNoN/A
Do you have any current physical conditions, problems or concerns?

YesNo
If yes, please specify concerns
Do you have any mental health conditions/co-occurring diagnosed disorders?

YesNo
If yes, please specify diagnosis/concerns
Do you currently have any allergies to any medications?

YesNo
If yes, please specify allergies:
History

Past and Current Medication

Rows	Name of Medication	Currently Prescribed? (Y/N)	Dosage/Frequency
1
2
3
4
5
6
7
8
9
10

Have you experienced withdrawal symptoms in the past?

YesNo
If yes, please mark all that you have experienced:

DiarrheaChills/SweatsTremors/ShakingIrritabilityNausea/VomitingAnxietyWeaknessHallucinationsTachycardiaIncreased Blood PressureOther
Have you ever received treatment for substance abuse in the past?

YesNo
If yes please describe:

Substances Used

Rows	Age of First Use	Date of last Use	Frequency/Amount Use
Alcohol
Marijuana
Opiates
Heroin
Cocaine/Crack
Benzodiazepines
Amphetamines
Hallucinogens

Appointment Request
Date of Requested Appointment

MonthDayYear
Date
Hour MinutesAM/PM Option
Please be aware that someone will call you regarding your appointment request within 24 business hours.

Please feel free to reach out directly at 412-440-7478 for additional information or assistance scheduling with AIMS.
Is there anything else you'd like us to know?
Program Requirements:
I understand that I must submit a urine drug screen monthly while enrolled in AIMS program.*

YesNo
I understand that I will meet with a member of my care management team twice per month as well as attend my regularly scheduled MAT appointment*

YesNo
I understand I must submit a valid identification card and insurance card prior to my first appointment. This can be submitted through my patient portal.*

YesNo
By submitting this form via this web portal, you acknowledge and accept that risks of communicating your health information via this unencrypted email and electronic messaging and wish to continue despite those risks. By clicking "Yes, I want to submit this form" you agree to hold Jade Wellness Center harmless for unauthorized use, disclosure, or access of your protected health information sent via this electronic means.**

Yes
Should be Empty:

Rows	Relationship	Name	Age	Monthly Gross Income
Self
Household member 1
Household member 2
Household member 3
Household member 4
Household member 5
Household member 6
Household member 7
Household member 8

Request an Appointment

Demographic Information

Funding Information

Emergency Contact

Pharmacy

PCP

History

Appointment Request

Program Requirements: