Initial Needs Assessment
(Detailed health history request will follow)
Name of Person Completing Form *
Your answer
Email *
Your answer
Patient Name *
Your answer
Patient Address *
Your answer
Patient Phone Number *
Your answer
Patient Birthdate *
Your answer
Patient Insurance Company or self pay *
Your answer
Insurance policy number
Your answer
Insurance Group number
Your answer
Do you want to wait until your insurance is approved or are you willing to self pay until approval? (Initial appointment fee is $1000-1500 depending on services needed) *
Conditions for which patient is requesting appointment *
Your answer
Lead time needed for travel arrangements *
Your answer
Special considerations
Your answer
Do we have your permission to store this data for future reference and scheduling purposes. (This data storage complies with HIPAA.) *
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