Self-Pay Intake Form
Fill out this form if you do not want us to bill insurance for your treatment.
Patient Information
First Name *
Please type your first name
Your answer
Last Name *
Please type your last name
Your answer
Date of Birth *
Please use the format MM/DD/YYYY
Your answer
Email
Your answer
Address *
Example: 12345 45th St. NW
Your answer
Apartment # / Suite #
* If applicable
Your answer
City *
Full Name
Your answer
State *
Your answer
Zip Code *
5 digits
Your answer
Home Phone *
Please use this format: 123-456-7890
Your answer
Cell Phone *
Please use this format: 123-456-7890
Work Phone
Please use this format: 123-456-7890
How did you find us? *
Referring party: Name and Phone
Your answer
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