New Patient Appointment Request
This is step 1 of 2 before you can book an appointment. Once this request is submitted you will receive further intake paperwork that has to be reviewed before you are approved to schedule.
Are you a current patient or have you been seen by Danielle Fitch in the previous 3 years?
Please Select
yes
no
Patient Name
Legal First Name
*
Legal Last Name
*
Preferred Name
Patient Details
Date of Birth
*
-
Month
-
Day
Year
Date
Is the patient under age 18?
*
Yes
No
Guardian Details
*
First Name
Last Name
Relationship to Patient
*
Please Select
Parent
Legal Guardian
Grandparent
Sibling
Other
Parent/Guardian Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian Email
example@example.com
Contact
Email Address for Next-Step Instructions After Request is Submitted
*
example@example.com
Phone Number That You Consent to for Contact
*
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Contact Method
*
Email
Phone
Text
Are you requesting urgent or emergency support today?
Yes
No
I understand this form is not for emergencies.
*
I understand
Care Request
Type of Service Sought
*
Medication Management and currently on medication
Medication Management currently NOT on medication
Evaluation for alternative options
Diagnosis Evaluation
Not sure
Brief Description of Help Needed
*
Insurance
How do you plan to pay for services?
*
Insurance
Self-pay (Cash Pay)
Not sure
Insurance carrier
Insurance plan type
Please Select
PPO
HMO
Medicaid
Medicare
Marketplace
Employer plan
Not sure
Member ID
Save
Submit New Patient Request
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