New Patient Registration Patient-Therapist Agreement 2024 Patient Registration Patient InformationEmergency ContactInsuranceCredit Card Authorization / Payment Option Assignment and Release Patient Information Last Name * First Name * Middle Name Address * Address Address Address City City State AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State Zip Code Zip Code Mobile Phone * Home Phone Date of Birth * Sex * MaleFemaleNon-binary Email * Social Security Number * Marital Status * SingleMarriedDivorcedWidowed Driver’s Licence State and ID Number Upload a photo of front of driver’s licence (jpg, png, gif, heic, and pdf files accepted) Drop a file here or click to upload Choose File Maximum file size: 100MB Employer Name Work Phone If voicemail is received, can a message be left on any of the numbers provided? * Yes No On which phone numbers can we leave a voicemail? * Mobile Home Work Will statements be sent to someone other than the patient? * Yes No Guarantor Information To whom statements are sent Name * Relationship to Patient Is the guarantor's address the same as the patient's address? Yes No Address Address Address Address City City State AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State Zip Code Zip Code Social Security Number Date of Birth Primary Phone * If you are human, leave this field blank. Next Δ
