Secure Contact Form

I understand that if my child is a legal adult (18+), they must fill out this form. This is required by HIPPA (Health Insurance Portability and Accountability Act).

First Name

Middle Initial

Last Name

Date of Birth

Email Address

Your client portal will be linked to this email address. Additionally, this email address is where you will receive appointment reminders. **Note: this is important for telehealth appointments.**

Phone Number

Please Include Area Code

Can our office call and/or send text messages to this number?

Yes No

Street Address

City

State

Zip

Add another child

Parent/Legal Guardian Information

First Name

Last Name

Date of Birth

Email Address

Your client portal will be linked to this email address. Additionally, this email address is where you will receive appointment reminders. **Note: this is important for telehealth appointments.**

Phone Number

Please Include Area Code

Can our office call and/or send text messages to this number?

Yes No

Street Address

City

State

Zip

Insurance

Insurance or Cash Pay

Insurance Cash Pay

Are you the primary insured?

Yes No

Member ID

Primary Insured: First Name

Primary Insured: Last Name

Primary Insured: Date of Birth

Primary Insured: Street Address

Primary Insured: City

Primary Insured: State

Primary Insured: Zip

Primary Insured: Phone Number

Please Include Area Code

Appointment

Please note: Due to state law, we can only provide telehealth appointments for individuals who live within the state of Arkansas or are located inside the state of Arkansas at the time of the appointment(s). If you have any questions, please call our office at 870.204.6016.

Your information will be encrypted.