Patient Intake
  • Patient Information
  • Emergency Contact
  • Insurance
  • Payment

New Patient Intake Form / Consent to Treatment

PATIENT INTAKE INFORMATION

First Middle Last
Address
Address
City
State/Province
Zip/Postal
Communication Preference
Please check yes if you would like to sign up for our patient portal (to communicate medication questions, appointment questions, refills):
Is the patient under 18?

Under 18

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.

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