New Patient Request

NEW PATIENT REQUEST FORM

* Indicates required field

Legal Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Email *

Cell Phone Number *

Is it ok to send you text reminders of appointments, cancellations and/or paperwork that is due? *

Yes No

Date of Birth *

Gender *

Which services are you requesting *

Time Zone *

Insurance *

Other Insurance Carrier (if not listed). Medicare and Medicaid are not accepted. *

Member ID *

Group Number *

Upload a copy of the front of your insurance card. *

Max file size: 20MB

Upload a copy of the back of your insurance card. *

Max file size: 20MB

MMCC ID #, if requesting certification for a medical marijuana card *

How did you find this provider? *

This request is not an emergency or urgent matter - I wish to proceed *

Yes

*This information will be sent to a non-HIPAA compliant email. Please note this is not a secure means of communication so your confidentially cannot be ensured.

Submit

Once you have been approved for services and your insurance has been verified you will receive an email from Headway to set up your account and schedule your first appointment. Headway is the healthcare portal used for scheduling, billing, messaging, and telehealth. In the meantime, if you could complete the Health History Form. This allows for your appointment time to be spent on the stuff that really matters, instead of just collecting history. This needs to be done within 24hrs of your first appointment so there is time to review the information. Thank you and feel free to Contact Us with any questions or concerns.

Health History Form