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Patient Information

Patient Information (We are not taking any New Patient's with any Medicaid plans)

Sex:(Required)
Preferred Language:(mark if Spanish Only and put note on reason to inform MA/Provider)(Required)

Medical Insurance

Responsible Party:
Responsible Party:

**If patient answered YES to any of the below questions, DO NOT SCHEDULE APPOINTMENT, approval will be required from Office Administrator**

**If patient answered NO to the above questions, inform patient if a medication is not listed, we may not be able to refill this medication at time of appointment and they will be referred to a specialist for treatment of that condition. All current medications will be reviewed at the time of the visit and the treating provider may discuss current and future medication regimens.**

Chronic Conditions

Are you currently taking any medication for Pain?(Required)
Are you currently taking any medication for Anxiety?(Required)
Are you currently taking any medication for Depression?(Required)
Are you currently taking any medication for Attention Deficit Disorder?(Required)
Are you currently taking any medication for Drug Withdrawal?(Required)
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NOTE: REMIND PATIENT TO BRING ALL MEDICATION BOTTLES, PICTURE ID OR DRIVERS LICENSE, INSURANCE CARDS ON DAY OF APPOINTMENT, AND IF NEW PATIENT PACKET EMAILED, TO RETURN BEFORE APPOINTMENT DATE.