Appalachian Wellness Center À la carte New Patient ID, History & Consent Form
Sign in to Google to save your progress. Learn more
Email *
Date of Completion of Patient ID Form *
Please Review & Complete this & all other forms.  The documents at the bottom of this form require your signature.They will need to be printed out and signed by you.  Please bring any insurance card(s)/information to your initial appointment and a government-issued photo ID such as a Driver's License.  We are participating providers with BCBS, Humana, Medicare, Medicaid for NC & SC.  We will bill private insurance carriers as a non-participating provider for other plans.  There is a $150 fee for missed 1 hour appt's and $500 for missed 4 hour appt's, this includes calling within 24 hours of your appointment to cancel. Having all information below helps us deal with any “Prior Authorization” requirements by any type of health coverage that you have.Thank you for choosing Appalachian Wellness!
First Name *
Middle Name
Last Name *
Preferred Name *
Date of Birth *
Gender *
Social Security Number
Cell Phone Number *
Home Phone Number
Work Phone Number
Preferred Means of Communication
Clear selection
Home Address 1 *
Home Address 2
Home Address City *
Home Address State *
Home Address Zip Code *
Clear form
Never submit passwords through Google Forms.
This form was created inside of Appalachian Wellness Ctr PLLC. Report Abuse