MATClinics Patient Intake Form & Patient Agreement
Please answer all of the following questions before you arrive for your appointment. This information will help us develop the right treatment for you, set up expectations for what MATClinics can and cannot do, and give us the ability to contact you in the way(s) that you prefer.

Once your information has been received by MATClinics, it will be maintained as set forth in our Privacy Notice detailed on the last page of this form (or available for review anytime at:

Please allow 20-30 minutes to complete. For Medicaid patients, the form is a bit more involved.

If you leave the form before you hit SUBMIT you will not be able to come back and start where you left off, so please try to find a time and place that will allow you to complete the form in one sitting.

If you have trouble using a computer or a smartphone to complete this form, one of our staff can sit down with you and collect all your information. Please let us know before you arrive for your appointment so we make sure that someone is available to help you.

Email address *
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