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New Patient Intake Form
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*Please provide copies of front and back of insurance card on form
Disclaimer: Thank you for your interest in being a patient of Partners In Integrative Healing. This form is used to collect information about new patients for both medical and mental health services and is for internal purposes only.
The information you provide is confidential and will be treated accordingly.
New patient requests are reviewed once weekly and will typically receive a response within 7-10 business days.
Completion of this form does not guarantee services from our clinic.
All New Patient Intake Appointments are billable visits; Intake Appointments will be billed to your insurance
or will be your responsibility cash pay if you are not using insurance.
This form is not for urgent or emergent requests.
If you feel you need to be seen urgently, please call 911, or present to the emergency department nearest to you.
If you think we might be a fit to help you reach your goals,
please fill out the New Patient Intake Form. ​​
Healthcare providers may fax referrals to (800) 292 7401.
If you are an established patient and wish to communicate
about your healthcare, please access the patient portal to send
a secure message to healthcare staff.
If you are a NEW patient who is completing new patient portal registration,
please access the patient portal registration here to complete the process.
We respond to patient messages within 72 business hours. The most effective way to reach staff is through the patient portal.
Please note: the new patient intake form and the patient portal are NOT for emergencies. If this is a medical emergency, please call 911.
*Universal Mobile Phone Consent; As current or prospective patient, you understand that you can text us STOP at any time to opt out of receiving SMS text messages from us. You can text HELP at any time to receive help.
You understand that the messaging frequency may vary.
Your mobile information will not be shared with any third parties/affiliates for marketing/promotional purposes. All policies are followed as per CTIA guidelines 5.2.1. At any time if you want your information to be removed, you can contact us via our email address or a regular mail.
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