New Beginning Health PC Instant Rapid PATIENT INTAKE FORM

New Beginning Health PC Rapid PATIENT INTAKE FORM
Disclaimer: Thank you for your interest in being a patient of [HEALTHCARE FACILITY'S NAME]. This form is used to collect information about new patients and used for internal purposes only. The information you supply is confidential and enrypted , secured and will be treated accordingly. Please see our HIPPA compliance stamp
PATIENT DETAILS
Name

First NameLast Name
We provide treatment for patients in recovery from addiction: Please check why you are choosing to fill out this form to become a patient

In Withdrawl need treatment ASAPWant To be treated with SuboxoneSwitching fro a clinicCourt orderedOther
Do you have health insurance: (We accept almost all major insurance plans we also have a cash pay option)

I have insuranceI do not have insurance but I will pay cash
Date of Birth:

MonthDayYear
Date
Gender:

MaleFemaleOther
Home Phone:
Mobile Phone:
E-Mail:
example@example.com

New Beginning Health PC Rapid PATIENT INTAKE FORM