Patient Intake Form
When Do You Want Your Appointment?
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Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Why are you making your appointment?
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Upload Front of Driver's License
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Upload Back of Driver's License
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If you plan to use insurance, upload the FRONT of your insurance card.
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If you plan to use insurance, upload the BACK of your insurance card.
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Credit Card Billing Information
For Insurance: we accept Medicare and Medicaid. You will be responsible for any co-pay (we will let you know if there will be a co-pay prior to charging your card). Non-Medicare/Medicaid visits are billed as out-of-pocket/cash pay. Out-of-pocket/Cash pay visits are $100. If no insurance information is uploaded, we will assume that the visit is a cash pay visit. We charge a $40 no-show fee if you miss your appointment or cancel with less than 24 hours notice. We do not charge your card until the day/time of the appointment.
Upload the FRONT of your credit card.
*
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Upload the BACK of your credit card.
*
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Submit
Should be Empty: