New Patient Enrollment Form

New Patient Enrollment Form

LIFETIME INSIGHT, LLC
This form will ask you many questions - your demographics data and verification of identity, the name and phone number of your primary care doctor, your social, medical, surgical, family, and psychiatric history, your current and past medications and allergies, and more.

Be sure to have your pill bottles (and vitamins/supplements) ready as well as the pharmacy address and phone number that you wish to use (we DO NOT send to local CVS pharmacies - NO EXCEPTIONS). We will not send to a mail order pharmacy the first time you are seen. No 90-requests will be approved unless you've been stable on a dose while in our care for a minimum of 2 months.

Full Name*

PrefixFirst NameLast NameSuffix
How did you find us?*
Please help us learn your secret to finding great care!
Name of referring doctor/therapist
Date of Birth*

MonthDayYear
Date
Age*
Picture of Your Drivers License or State ID to verify identity*
Take a Selfie for our Medical Records*
Patient's SS#*
Biological Sex*

MaleFemale
Gender Identity*

MaleFemaleTranssexual MaleTranssexual FemaleNon-binaryOther
Mobile Phone*
Email*
Do you agree to receive reminders by email and text?*
NOTE: If you choose "No", we have the right to refuse to provide treatment. Please see office policies.
Home/Residential Address*

Address

Line 2

CityState

Zip Code
Emergency Contact Name*
Emergency Contact Relationship*
Emergency Contact Phone*
Primary Care Clinician
Please provide as we like to coordinate care
Primary Care Clinician Phone Number
Neurologist, if any
Please provide as we like to coordinate care
Preferred Pharmacy Name*
WE DO NOT WORK WITH CVS
Pharmacy Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preferred Pharmacy Phone Number*

Area CodePhone Number

Reason for Visit