DRAFT NEW PATIENT FORMS

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Online Intake - Healthy Brain Center - Adult & Geriatric Psychiatry (Adults 18+)

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Patient's First Name: *

Patient's Last Name: *

Date of Birth: *

E-mail address: *

Cellphone: *

Health Plan Name (i.e., United Healthcare, Blue Cross) *

Insurance ID# *

Tel # on back of Insurance Card for Providers or Eligibility *

SECONDARY Insurance Company *

SECONDARY Insurance ID# *

Your Mailing Address (Cannot process without all these details: Street, City, State, Zip) *

Reason for Visit (IMPORTANT: Writing "I need a new psychiatrist" or "Medication" will delay your application. Please be VERY specific about your symptoms or event leading to this visit and why you need to see a psychiatrist, or application will not p *

Allergies to Medication: *

Captcha (spam protection code) *

Note: Fields marked with * are required

**DRAFT** NEW PATIENT FORMS

DRAFT NEW PATIENT FORMS