Patient Information

Please fill this form out only after you have a new patient appointment scheduled

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First Name *
Middle Name
Last Name *
Address (no PO Box) *
 
City *
State
ZipCode *
Phone Number 1 *
Phone Number 2
Your Email Address *
@
I authorize email communication *
(e.g. Appointment Reminders, Medical Questionnaire, Health Bulletins)
I authorize reminders by phone *
 
SSN (last 4 digits)
Age *
Date of Birth *
Gender *
Emergency Contact *
Spouse / Partner
Family Doctor
Therapist / Counselor
Other Specialist
I acknowledge and agree to have my prescriptions sent by electronic transmission. I understand that it is office policy not to call in prescriptions.
Authorization: I hereby authorize the use of above information as well as any pertinent clinical information necessary for billing and/or obtaining pre-certification for medication and Initial/follow up visits. I understand that I am financially responsible for all charges, whether or not paid by the insurance. Since we reserve the time for you, there is a $40 No Show fee and $20 late cancellation fee for appointments cancelled within less than 48 business hours, to be paid in full by me.
Signature

2301 Evesham Road,
Suite #108, Voorhees, NJ 08043


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