Patient Information & History

Please fill this form out only after you have a new patient appointment scheduled

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First Name *

Middle Name

Last Name *

Address (no PO Box) *
Address

City *

State

ZipCode *

Phone Number 1 *

Phone Number 2

Your Email Address *

I authorize phone/email/text communication *
(e.g. Appointment Reminders, Medical Questionnaire, Health Bulletins)

SSN (last 4 digits)

Age *

Date of Birth *

Gender *

Referred By

Emergency Contact *

Spouse / Partner

Family Doctor

Therapist / Counselor

Other Specialist

I acknowledge and agree to have my prescriptions sent by electronic transmission. I understand that it is office policy not to call in prescriptions.

Authorization: I hereby authorize the use of above information as well as any pertinent clinical information necessary for billing and/or obtaining pre-certification for medication and Initial/follow up visits. I understand that I am financially responsible for all charges, whether or not paid by the insurance. Since we reserve the time for you, there is a $50 No Show fee and $25 late cancellation fee for appointments cancelled within less than 48 business hours, I agree to 'No Show' and 'Late Cancellation fees'

Signature at office

Submit

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Patient Information & History