CP/Demo E-Form

Client Profile/Demographics

+Gen. Terms, BI Auth, Tx Consent/Privacy
Terms Reference: hhbrainhealth.com/general
Patient/Client Name*

First NameLast Name
Date of Birth*

MonthDayYear
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preferred Phone #*

Area CodePhone Number
Preferred Email*
example@example.com
Emergency Contact*

First NameLast Name
Relationship to Pt/Client*
Ex. Mother, Friend, Uncle, etc
Emergency Contact Phone Number*

Area CodePhone Number
What Is Pt/Client's Interest In HH Services? *
Ex. Intro Services, Intensive Program, Medical Consult, etc
Pt/Client Clinical History & Medication(s):*
Brief Summary of Relevant History & Current/Recent Medications
Insurance Carrier
(Private Carrier, Medicare, Other)
Ins. Member ID #
Referral Source: (Please check all that apply)*

Social MediaInternet SearchFamily or Friends NetworkHealthcare Provider or OfficeNeurostar (Neuronetics)Print/Listing/PromoOther
If Pt/Client is too young or does not otherwise have License or ID, please include License or ID of Pt/Client's designated Guardian or Emergency Contact.
Pt/Client License or ID Card (FRONT ONLY)*

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By signing & submitting CP/Demo, Patient/Client (or Guardian) hereby agrees to HH's Gen. Service Terms which includes the content of Benefits Authorization, Consent/Privacy & Standard Tx Guide disclosures.
Guardian Name (If Applicable)

First NameLast Name
Pt/Client or Guardian Signature

Clear
Should be Empty:

Client Profile/Demographics