Buprenorphine Treatment Inquiry
In order to be placed on our waiting list for opioid dependence treatment with buprenorphine, please answer all questions below and submit this form. We will notify you if you are eligible for treatment and once we have an opening in the program. Thank you!
Email address *
Patient Name *
Date of Birth *
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Phone Number (please include area code) *
E-mail Address
Have you tried Buprenorphine before? *
This includes in any formulation - Subutex, Suboxone films, Suboxone tablets, Zubsolv, Belbuca, Buprenex, and Butrans.
Select all substances you are taking currently, or have taken recently. *
Include anything you are taking with or without a prescription
Required
Please list any chronic health problems. *
Are you currently being treated by another provider for substance abuse? If so, who is treating you? *
How did you hear about our program? *
How will you be paying for your treatment? *
Please note that we are not in network with Kancare or Medicaid.
Do you have a Primary Care Physician? *
Do you have a Counselor or Psychiatrist? *
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This form was created inside of Healthy Strategies Family Doc, PA.