Patient Intake Patient InformationEmergency ContactInsurance Payment 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 AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Date of Birth * 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
