Patient Information & History

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

Note: All requested data is secured as our site uses SSL (Secure Sockets Layer) to protect your data from theft. Please feel free to submit your personal details in the form below. Click here to view SSL certification.

First Name *
Middle Name
Last Name *
Address (no PO Box) *
City *
ZipCode *
Phone Number 1 *
Phone Number 2
Your Email Address *
I authorize phone/email/text communication *
(e.g. Appointment Reminders, Medical Questionnaire, Health Bulletins)
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 $50 No Show fee and $25 late cancellation fee for appointments cancelled within less than 48 business hours, I agree to 'No Show' and 'Late Cancellation fees'
Signature at office

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

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