New Patient Form

Let’s Get To Know You Better.

 

Your information is confidential. Always.

 

the answers you provide allows us to help you!

Name *
Name
Birthdate: *
Birthdate:
Biological: *
What Are You Concerns (check all that apply)? *
It's important to communicate! Please enter your contact information below.
Phone *
Phone
Check All The Ways You Want Us To Contact You: *
Great! Now, let's get some other basic information below:
Emergency Contact:
Emergency Contact:
Emergency Contact's Number:
Emergency Contact's Number:
Blue Cross, or Medicaid, or United, etc.
Awesome! Now let's get to know more about you as a person!
Which best describes your current relationship status? *
Do you have kids or are you responsible for any kids (Guardian)? *
Example: 12, 10, and 3
Are you currently working? *
Are you the primary homemaker? *
You're almost done! Let's get to know your health:
Are you actively using any of the following (check all that apply): *
Which best describes your nicotine use? *
Check all that apply:
Which best describes your alcohol use? *
Pick the best one that describes you
Such as certain medications, foods, etc.
For example: Xanax 1mg twice a day, Lasix 20mg once a day, etc.
For example: lower back surgery in 2015, appendix removed, etc. Try to include the year of the procedure if possible and explain any complications.
If you have medical problems, let us know which body system (check all that apply):: *
Check any of the psychiatric conditions that you may have:
For example: I had asthma as a kid, or I have had two heart attacks, a stroke, and jungle fever.
Last section but it's really important!
Check any statements below that apply to you: *