Master Form Patient InformationEmergency ContactInsurancePaymentHIPAANo show policyTelemed policyEmail policyPHQ9GAD7 ROI New Patient Intake Form / Consent to Treatment Date PATIENT INTAKE INFORMATION Name * First Middle Last Email * Cell Phone * Alt. Phone Address * Address Address Address City City State/Province Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State/Province Zip/Postal Zip/Postal Date of Birth * Please double-check your birth year before submitting. Age * Gender * Communication Preference Email Phone Please check yes if you would like to sign up for our patient portal (to communicate medication questions, appointment questions, refills): * YES NO Marital Status: * Spouse/Partner's Name: Highest Grade/Degree * School, if student: Employer Job Title Is the patient under 18? * YES NO Under 18 Parent/Guardian Name: * Address (if different than above) Phone * I understand tha by signing this form I am identifying myself as the legal guardian of the above-named person. If you share guardianship/custody with another individual, please identify this person and a contact phone. Parent/Guardian Name: * Phone If you are human, leave this field blank. Next
