Request an Appointment Step 1 of 4 25% Patient InformationRequest Service For:*Check All That Apply Psychiatry Psychotherapy Patient Name* First Name Middle Initial Last Name Gender*MaleFemaleDate of Birth* Date Format: MM slash DD slash YYYY Age (ex 23)*Marital Status*singlemarrieddivorcedseparatedotherPerson Requesting Appointment* First Name Middle Initial Last Name Relationship to PatientAddress* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code County*AlleghenyBeaverButlerWashingtonOtherHome/Main Phone Number*Cell PhoneEmail* Referred By:Reason for Referral*Current Treating PhysicianAre you taking any medication currently?*YesNoWhat medications are you taking?Allergies*Emergency ContactEmergency Contact* First Last Emergency Contact Phone*Emergency Contact Relationship*Responsible Party*If patient is a minor or has a legal representative or guardian, additional information is needed.PatientGuardian or Legal RepresentativeResponsible Party InfoResponsible Party* First Last Responsible Party Address(if different from patient) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Responsible Party Phone*Responsible Party Email* Insurance InformationPrimary Insurance*Primary Insurance Group NumberPrimary Insurance Policyholder Name* First Last Primary Insurance Policyholder Relationship to Patient*Primary Insurance Policyholder Date of Birth* Date Format: MM slash DD slash YYYY Primary Insurance Policy Number*Do you have another insurance policy?*YesNoSecondary Insurance*Secondary Insurance Group NumberSecondary Insurance Policyholder Name* First Last Secondary Insurance Policyholder Relationship to Patient*Secondary Insurance Policyholder Date of Birth* Date Format: MM slash DD slash YYYY Secondary Insurance Policy Number* Workers Comp / Auto ClaimsIs this a worker's compensation or auto claim?*YesNoCase Manager*Insurance Company Name*Insurance Company Phone Number*Claim Number*Date of Injury* Date Format: MM slash DD slash YYYY Comments Appointment TimeCheck all days and times you are available to come in for an appointment.Day of the week* Monday Tuesday Wednesday Thursday Friday Time of day* 9am-Noon Noon-4pm Questions/CommentsWould you like to sign up to receive updates and important announcements?*Yes please!No thanks.NameThis field is for validation purposes and should be left unchanged.
