Intake Form

* Required Information

Date *

Agent/Representative Name

Client Name

Date of Birth

SS#

Client Information

Home Phone

Cell Phone

Email Address

Address

City

State

ZIP Code

Insurance Name

Insurance ID #

Group #

Reason for Visit

Medication Allergies (if any)

Pharmacy Name and Address *

Is this visit in seek of Benzeondiazepines? (Please answer Yes Or NO)

Yes

Previous Customer?

Is this visit solely in seek of FMLA? (Please answer Yes Or NO)

Yes

Availability for Follow-ups

Is this visit in seek of stimulants? (Please answer Yes Or NO)

Yes

Referred by

I consent to the collection and processing of my personal information and, where applicable, health-related information, including any data I submit on behalf of others. This is for the purpose of evaluating or fulfilling my request, in accordance with the Privacy Policy.

INTAKE FORM

Client Information