PLEASE COMPLETE & E-SIGN THE FORMS REQUESTED BY OUR STAFF:

NEW PATIENT INTAKE FORM

All New Patients - Complete this form prior to first visit

MENTAL HEALTH INTAKE FORM

All new Mental Health Patients - Complete this from prior to first visit

Telemedicine Consent Form

Complete this form to Consent to Telemedicine Services for remote medical care

Chronic Care Consent Form

Complete this form to Consent for Chronic Care Management

Chronic Pain Management

Complete this Form for Chronic Pain Management Contract

Release of Medical Records Request

Complete this form to Consent to Telemedicine Services for remote medical care

Buprenorphine (Suboxone/ Subutex) MAT Consent Form

Complete this Form to Consent for buprenorphine Medication-Assisted Treatment (MAT)

Depression Screening Brief Survey

Complete this Depression Screening Evaluation Form for your provider to interpret and discuss with you on your visit

PREGNANT PATIENT Office Based Addiction Therapy

Complete this Form to Consent for Office Based Addiction Therapy during Pregnancy

DAST Screening Test

Complete this Form for your DAST Screening if your Provider requests it

CASE MANAGEMENT Consent Form

Complete this Form to Consent for Case Management

Consent for DPMA Birth Control

Complete this Form to Consent for Medication Injections of Depot Medroxyprogesterone Acetate (DMPA)

ADDITIONAL FORMS:

Testosterone Replacement Therapy Consent Form

Complete this Form to Consent for Testosterone Injections or Topical Medication

More Forms Soon