New Patient Contact Form

First Name

Middle Name

Last Name

Please type full name as it appears on your health insurance card.

Mailing Address

City

State

Zip Code

Phone Number

Date of Birth, MM/DD/YYYY

Sex

Type of Phone for Phone Number Listed Above Choose One

Mobile Phone Home Phone (Land Line)

Marital Status

Please only type in your personal email address. No work or school email addresses.

Email Address

Emergency Contact Name

Relationship to You

Emergency Contact Phone

Preferred Pharmacy Name

Pharmacy Zip Code

Pharmacy Phone Number

Primary Health Insurance Company Name

Primary Health Insurance ID Number, include Prefix and Suffix if applicable

Primary Health Insurance Group Number

Please include details on any secondary insurance plans below. This includes any Medicare or Medicaid plans.

Secondary Health Insurance Company Name

Secondary Health Insurance ID Number, include Prefix and Suffix if applicable

Secondary Health Insurance Group Number

Preferred Type of Appointments Choose One

In Person Appointments Telemedicine Appointments

Do you want appointment reminders via text messages?

Yes No

Reason You Want to See Me

List of Medications with Dosages, Type None if None

Please list all medications you are taking, including psychiatric medications and non-psychiatric medications. Include medication mg strengths and directions. Thanks.

Medication Allergies, type none if no drug allergies.

Please include all medication allergies, including psychiatric and non-psychiatric medications

How did you hear about me, or who referred you to me?

Your information will be encrypted.