New Patient Request

1
Name* This field is required.
First Name
Last Name
2
Date of Birth* This field is required.
Date
Month
Day
Year
3
Sex (assigned at birth)* This field is required.
Female
Male
4
Phone Number* This field is required.Please double check to make sure your phone number is correct
5
Email* This field is required.Please double check to make sure your email is correct
example@example.com
6
Do you live in Arizona?* This field is required.Sustained Recovery can only see patients who are able to provide an Arizona address.
Yes
7
Which medication(s) are you interested in?* This field is required.
Suboxone (buprenorphine/naloxone)
Naltrexone
Comfort medications
I'm not sure
Other
8
Are you already taking your preferred medication(s)?
Yes
No
Not currently, but I have taken it in the past
9
Is AHCCCS your primary insurance?* This field is required.Sustained Recovery cannot accept payment from patients who have AHCCCS as their primary insurance
No
10
Payment* This field is required.After your payment, you will be able to schedule your first appointment.
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ORDER SUMMARY
Total costUSD
Initial Intake and First MonthReceive an in-depth assessment and discuss your treatment options. The price of the initial assessment includes the follow up appointments within the first month that you and your provider feel you need.
$149.00Edit
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Total cost $0.00
Credit Card
First Name
Last Name
11
Thank you for choosing Sustained Recovery! Please choose a preferred appointment time. If you do not see an appointment that is soon enough, please notify us at 602-345-1233 or info@sustained-recovery.com:* This field is required.By submitting this form, you are authorizing Sustained Recovery to contact you by phone (call or text) or email.
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