New Patient Form

Total health Services

Once completed, please email to intake@total-healthservices.com
DEMOGRAPHICS
Patient Name

First NameMiddle NameLast Name
Birth Date

MonthDayYear
Age
SSN
SSN
Gender assigned at Birth
If Minor, Legal Guardian
Are there custody issues?

YesNo
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Cell Phone
E-mail
example@example.com
For patients with a Power of Attorney, please include your POA paperwork with this form.

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Pharmacy Information
Pharmacy name
Pharmacy Address
Pharmacy phone number
Primary Insurance: (please include a front and back picture of your insurance card with this form)

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Insurance Company
Phone Number (on back of card)

Secondary Insurance: (please include a front and back picture of your insurance card with this form)

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Insurance Company
Insurance Company
Phone Number (on back of card)
Subscriber Name
Subscriber DOB

MonthDayYear
Subscriber Employer
Relationship to Subscriber
Member ID
Group Number
Tertiary Insurance: (please include a front and back picture of your insurance card with this form)

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Insurance Company
Phone Number (on back of card)
Subscriber Name
Subscriber DOB

MonthDayYear
Subscriber Employer
Relationship to Subscriber
Member ID
Group Number

Current and Past Medications

Please note which medications are current and the dosage. If you do not remember the dose or directions, that is okay.

Antidepressants

Anti-Anxiety/Sleep Agents

Mood Stabilizers

Dopamine Blockers

	Current or Past	Dose	Directions	Side Effects
Thorazine
(chlorpromazine)
Stelazine
(trifluoperazine)
Prolixin (fluphenazine)
Trilafon
(perphenazine)
Haldol (haloperidol)
Clozaril (clozapine)
Zyprexa (olanzapine)
Risperdal
(risperidone)
Seroquel (quetiapine)
Geodon (ziprasidone)
Abilify (aripiprazole)
Fanapt (iloperidone)
Saphris (asenapine)
Latuda (lurasidone)
Vraylar (cariprazine)
Caplyta
(lumateperone)
Invega (paliperidone palmitate)

Attention Deficit Medications

Substance Use History

	Current Use? (Y/N)	Past Use? (Y/N)	How much are you using now?
Alcohol
Nicotine (cigarettes, vapes, chewing
tobacco, etc)
Caffeine
Marijuana / THC
Opioids / Pain
medications that are not prescribed
Street Drugs
(cocaine, heroin, MDMA, acid, LSD, etc)

	Other	Current Use? (Y/N)	Past Use? (Y/N)	How much are you using now?
Friendliness

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