New Patient Information Form
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If you're interested in a New Patient Appointment with Dr Earthman please fill out the information below and it will be sent directly to Dr Earthman's office staff. Upon receipt and review of your information we will call you to set up an appoinment. Thank you
Name: First, Middle Initial, Last
Home Address
Date of Birth
Home Phone: ( ) -
Work Phone: ( ) -
Cell Phone: ( ) -
Primary Insurance Company
Contact Phone # from the back of your Insurance card (Behavioral Health / Provider Relations) -
Member ID #
Group ID #
Name of Primary Insured
Date of Birth of Primary Insured
Are you currently applying for Disability or FMLA?
Yes
No
Have you been hospitalized for any psychiatric reason in the past 5 years?
Yes
No
If you have been hospitalized in the last 5 years, please notate below where, when, and for what reason you were admitted.
Have you had any suicide attempts in the past 5 years?
Yes
No
What are some of the current problems you're experiencing?
Depression
Anxiety
Insomnia
Addiction
Bi-Polar (manic/depressive)
Stress
Feeling overwhelmed
Other
Please be aware that we have an office policy requiring that you call to cancel any scheduled appointment at least 3 business days prior to your scheduled appointment. If you miss or reschedule with less than 3 buisness day notice we reserve the right to automatically charge your credit card on file a fee equal to your insurance contracted rate or the private pay rate. Please acknowledge that you have read and understand both this policy by placing your INITIALS in the box below.
Dr. Earthman requires that you complete the Medical/Psychiatric History Form located on this website and bring it with you to your appointment. Or, you may come 1 hour prior to your appointment and fill it out in our lobby. If you do not have this form completed Dr. Earthman will not see you and we reserve the right to automatically charge your credit card on file a fee equal to your insurance contracted rate or the private pay rate. Please acknowledge you have read and understand this policy by placing your INITIALS in the box below.
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