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NEW PATIENT FORM, Page 1 of 2

Welcome to Advanced Psychiatric Therapeutics appointment request form!
We look forward to helping you. Please answer the questions below to assist us in establishing you with a provider.


PATIENT INFORMATION:
*First Name:
*Last Name:
*Gender: Male
Female
Other:
Prefer not to say
*Phone Number (xxx-xxx-xxxx):
*Address:
Address (line 2):
*City:
*State:
*Zipcode:
*Email Address:
*Date of Birth (mm/dd/yyyy):
Were you referred by a specific provider? If so, who?
Are there any other people that should be kept in the loop (Case Managers, Family Members, or another Provider)? If so, who?
*Most Providers are seeing patients by Telehealth. Is this okay for you? Yes, telehealth is fine/preferable
No, I would like to see someone in person
*Would you like to be established with a particular provider? I would prefer to see whichever provider can see me first.
I would like to select a specific provider.