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NEW PATIENT
REGISTRATION FORMS


"ALL (3) FORMS BELOW MUST BE COMPLETED"
(48) hrs prior to your scheduled appointment

our intake forms are digital, 
there is no need to print or download. 

SIMPLY CLICK EACH LINK BELOW, COMPLETE & SUBMIT


PLEASE NOTE!!
IF ALL (3) INTAKE FORMS ARE NOT COMPLETED OR INCOMPLETE,
YOUR APPOINTMENT MAY BE RESCHEDULED.

 

CANCELLATION POLICY

NEW PATIENT CANCELLATION or RESCHEDULE:

If it is necessary to cancel your appointment, you are required to CANCEL OR RESCHEDULE at least (24) BUSINESS HOURS from YOUR SCHEDULED APPOINTMENT (DATE & TIME), otherwise you will be charged the full SELF PAY RATE of the missed appointment. 

 

NEW PATIENT LATE ARRIVAL or NO SHOW:

If you are more than (10) minutes Late or Not Available for the scheduled appointment (via; Office, Phone, or TelePsychiatry) you will be charged the full SELF PAY RATE of the missed appointment.

 

This gives us an opportunity to reallocate time for another patient in need of care. 

Thank you.

PATIENT FORMS
our forms are digital, there is no need to print or download

Medical Records
&
Release of Information

Existing Patients
"CII Refill Request"

Patient Letter, form & Documents

Make a One Time Payment
"Digital Form"

Drug Assistance Program
Many pharmaceutical companies, state programs and nonprofits have drug assistance programs (PAPs) that offer free or low-cost medications if you don't have insurance or are under insured and can't afford your medications. 

You may qualify for free medications if you do not have health insurance, do not have enough health insurance to cover your medications or meet certain criteria. 

Below is a list of several organizations that may be able to offer assistance.

Call our office to discuss your options.

 

TAKEDA
Patient Assistance Program


Medications:

*Trintellix  *Carbatrol


*Rozerem

Image by Tiago Alexandre Lopes

 

Patient Assistance Programs

Enrollment Application

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