Integrative Sexual Health New Patient Request Form

Integrative Sexual Health & Wellness New Patient Request Form

Thank you for your interest in seeing me at my Integrative Sexual Health & Wellness Practice.

We’ve created a simple online form for you to communicate with us in a secure and confidential manner. We try to respond to all new patient requests within 3 business days (feel free to call if you haven’t heard back from us within a week).

Please be advised that by using this form to contact our office, we are not confirming an appointment nor establishing a physician-patient relationship. As a user of this mode of communication and of our website, you assume all risks with placing confidential information into this portal. This form of communication is not intended for acute, emergency, or life-threatening health conditions. If you believe you are having a health emergency, contact 911 or go to your nearest emergency department.

Name

DOB (mm/dd/yyyy)

Current Insurance

Member ID# (from insurance card)

Insurance ID# (if different from Member ID)

Do you need to be seen immediately? Do you need to be seen immediately? Yes No

Reason (if yes)

Please list any ongoing medical issues

Please list all current medications

How did you hear about my Sexual Health & Wellness Practice?

Please list the best contact # for you

Please enter your email address