Prospective New Patient Demographics

In preparation for your first visit with Said A. Ibrahimi, M.D., Vortex Psychiatry, we will need some information.

Once we have verified your insurance benefits, a member of our staff will contact you as soon as possible to schedule your appointment. Please complete the information below.

Patient First Name

Patient Last Name

Patient Date:

Patient Email

Patient Address (Street, City, Zip Code)

Best Contact Phone Number

Other contact phone number

Leave message on voicemail

Yes No

Leave message with person(s)

Yes No

Person name to leave message:

IF MINOR:

Parent/Guardian First Name

Parent/Guardian Last Name

Parent/Guardian (Complete address, if differs from above)

Best Contact Phone Number

Other contact phone number

If MINOR: Does the patient live with both parents?

If not, is there a custody order?

Patient Email

Brief Reason for Appointment:

Who were you referred by?

Insurance Provider (if applicable):

Insurance ID# (Please include any letters):

Insurance Group number, Local number

Please include Mental Health/Provider Services Phone Number: (Can be found on front or back of insurance ID card)

Your information will be encrypted.