Patient Registration

Client Information and Participation Agreement This information will be used to aid in serving you as the client. Please answer honestly and know that answer yes or no to any particular question does not mean that you cannot receive services from this practitioner. Your honest answers serve in your receipt of appropriate care and services. All information will be kept confidential with the Health Insurance Portability and Accountability Act (HIPAA) regulations.

First Name *

Last Name *

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Is it ok to leave a message and text to this number? *

Yes

No

Other Other

Email Address *

Is it ok to email this address? *

Yes

No

Other Other

Date of birth: * +

Age *