Patient Information Form

Fields with an asterisk (*) are required.

Today's date:*

MonthDayYear

Patient Referred By*

Doctor*

Dr. William Lee M.D.Dr. Kristeen Spratley M.D.Dr. John Burnside M.D.

Date of Scheduled Appointment if known

MonthDayYear

Patient's full name:*

First NameLast Name

Patient's sex:*

MaleFemale

Patient's marital status:*

SingleMarriedDivorcedWidow(ed)

Patient's Age:*

Patient's Birthdate:*

MonthDayYear

Social Security Number*

Patient's address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Patient's phone #1:*

Area CodePhone Number

Patient's phone #2:

Area CodePhone Number

Patient's email:

School or employer:*

Grade or position*

Preferred Pharmacy Address and Telephone*

Responsible Party Information

Patient & responsible party have the same name, address, and information:*

YesNo (Complete information below.)

Responsible party's name:

First NameLast Name

Birth Date

MonthDayYear

Social Security Number

Drivers License #*

Responsible Party's Employer

Responsible party address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Responsible party's phone #1:*

Area CodePhone Number

Responsible party's phone #2:

Area CodePhone Number

Responsible party's email:*

BELOW YOU WILL FIND OUR POLICY REGARDING PAYMENT, PRESCRIPTION REQUESTS ETC. SHOULD YOU HAVE ANY QUESTIONS, PLEASE DON’T HESITATE TO ASK AT THE FRONT DESK. WE WILL BE HAPPY TO ASSIST YOU.

· PAYMENT FOR SERVICES ARE EXPECTED IN FULL AT TIME OF SERVICE, UNLESS PRIOR ARRANGEMENTS HAVE BEEN MADE WITH THE DOCTOR. (see insurance info below) Some appointments require a credit card to be placed on file before they are scheduled.

· OFFICE HOURS: Monday – Thursday 9:00-12:00 and 1:00-6:00. Appointment hours may vary.

The office is closed on Fridays .In case of emergency please remember your first call should be 911

· PRESCRIPTIONS: Please allow 48 business hours for refills. It is the patient’s responsibility to check the status of prescriptions. Stimulant prescriptions must be filled within 21 days. All expired prescriptions must be returned before a new prescription can be issued. There will be a $15.00 fee to re-write expired prescriptions.

Refill requests can be submitted via the website at:

http://www.adhdclinicsa.com >> Prescription Requests and Concerns tab

Please be aware that prescriptions written between appointments will incur fees. Please see the website for more information.

Controlled Substance Prescriptions must be picked up or mailed. They cannot be called in.

For non- stimulant prescriptions, please have your pharmacy fax a refill request (no charge).

· CANCELLATIONS: Please give at least 24-hour notice when canceling an appointment. Late cancellations are billed at full office visit fee. A credit card will be required to keep, on file, for future appointments. You must cancel appointments before 5:00 the day prior to avoid a late cancellation charge. Leaving a message on the voice mail will incur a late cancel fee.

· "NO SHOW" APPOINTMENTS: Will be billed at full office visit fee. A credit card will be required to keep, on file, for future appointments.

· EMAILS – Emails for the doctors can be found on the website. Please feel free to email the doctors and allow up to 72 hours for a response. Emails are only accessed during regular office hours.

· REMINDER CALLS: ADHD Clinic does not guarantee reminder / confirmation calls. We do our best to make reminder calls, but there may be occasions when we will be unable to do so. We will be glad to give you an appointment card as a reminder when you schedule your appointment. No show / Late Cancel fees will still apply if appointments are missed.

· CONFIDENTIALITY: Information from this form, or disclosed in a session, is considered confidential and will not be shared with any individual or agency without written consent of the client(s), except as noted in the paragraph below.

· LEGAL OBLIGATION: I am legally obligated to warn of imminent danger. Circumstances, which override professional confidentiality, include, but are not limited to, actual or suspected physical or sexual abuse of a minor or elder, actual or suspected suicide or homicide, and cases where a legal subpoena is involved.

· COLLECTION FEES: Any collection fees or NSF charges due from non-payment on patient accounts are the responsibility of the patient or their responsible party.

· INSURANCE: We do not accept insurance. You will be given a statement that includes CPT codes each time you visit. You will also receive a copy of your diagnosis codes on your first visit. Please keep this as you will need it to file. You will need to complete the form required by your individual insurance company to receive any reimbursement. A charge may be incurred for additional copies of statements or diagnosis letters. It is the responsibility of the patient, or parent, to follow-up with any insurance discrepancies. Please keep your information current. Reimbursement payments made by insurance companies should go back to the insured, however, if an insurance company sends payment to our office they will be credited to the patient’s account.

Thank you!

Dr. John Burnside MD

Dr. Kristeen Spratley MD

Dr. William Lee MD

Dr. Louise O'Donnell Ph.D

By typing your name in the text box below, you certify that you have have read and understand the "Terms of Payment Agreement" above and you assume all financial responsibility for your total bill and give voluntary consent to receive treatment.

Responsible party (Full Name) approval:*