EmailMe Form - NEW PATIENT REGISTRATION

Name *

First Middle Last

Date of Birth *

MM / DD / YYYY

Phone *

### - ### - ####

Email *

Address *

Street Address City State / Province / Region Postal / Zip Code

Insurance Company

Member ID Number

Group Number

Social Security Number

Primary Policyholder’s Name

Insurance Card (front) *

May use credit card if paying private, request for credit card authorization form

Insurance Card (back) *

Back of credit card if paying private

Signature

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I authorize Vitality to store my credit/debit card information and automatically charge my credit/debit card for payments related to treatment

Picture ID *

driver or state license, passport, parent's ID

Emergency Contact Name

First Last

Phone

### - ### - ####

Relationship

Email

Allergy

Medical History

asthma, migraine, hypertension, etc

Surgical History

appendectomy, tonsillectomy

Psychiatric History

depression, anxiety, adhd, bipolar, etc

Addiction History

opiates, alcohol, cannabis, nicotine, detox and rehabilitation

Legal/Arrest History

Current Medications

Family Psychiatric History

mom-depression, brother-adhd

Primary Care Physician and/or Additional Therapist/Psychiatrist

Pharmacy name, address, and phone number

Checkbox

PATIENT TREATMENT CONTRACT

As a participant in treatment at Vitality Psychiatry Group Practice for medication management and/or therapy, I freely and voluntarily agree to accept this treatment contract as follows:
1. I agree to keep and be on time to my scheduled appointments. If I cannot keep my appointment at its scheduled time, I will call the office to cancel at least 24 hours prior to my scheduled appointment. Failure to give 24 hours notice of a cancelled appointment with result in a $40.00 fee that will be assessed to me, the patient, at my following visit.
2. I agree to conduct myself in a courteous manner while in the physician’s office, as well as through any phone, email, or other forms of communication with all office staff.
3. I agree to adhere to the payment policies outlined by this office. Payments must be made via cash, credit, debit, certified check, cashier check, or money order. Personal checks are NOT an acceptable form of payment. If for some reason a personal check is accepted and it is returned for ANY reason, you are subject to the original check amount, an additional $50.00 returned check fee from Vitality, as well as any fees associated with your bank.
4. I agree to give a minimum of 48 hours notice for any medication refill requests. Refill requests that have been granted by your physician, will be subject to a $25.00 fee per incident.
5. I agree not to sell, share, or give any of my medications to another person. I understand that such mishandling of my medications is a serious violation of this agreement and would result in my treatment being immediately terminated without any recourse for appeal.
6. I agree not to conduct any illegal or disruptive activities in or on Vitality property.
7. I understand that any illegal or disruptive activities I am party to which happen outside of Vitality and are reported to Vitality may lead to termination of services from Vitality.
8. I agree that my medications/prescriptions can only be given to me at my scheduled office visits. A missed appointment may result in I, the patient, being unable to receive my medications/prescriptions until my next scheduled visit.
9. I agree that my medications are my responsibility. I agree to keep my medications in a safe, secure place. I agree that my medications will NOT be replaced unless a police report is given to Vitality.
10. I agree not to obtain medications from any doctors, pharmacies, or other sources without informing my physician at Vitality.
11. I will make my physician aware of all medications I am currently prescribed, including those given by other treatment providers.
12. I agree to take my medications as instructed by my physician, without altering how I take my medications without first consulting with my physician.
13. I understand that medication alone is not sufficient treatment for my condition, and I agree to participate in counseling as discussed and agreed upon with my physician and specified in my treatment plan. Regular participation in counseling services is REQUIRED to maintain medication management services at Vitality.
14. Vitality does not take any responsibility for any failure of insurance reimbursements.

I UNDERSTAND THAT VIOLATION OF ANY OF THE ABOVE MAY BE GROUNDS FOR
TERMINATION OF TREATMENT AT THE DISCRETION OF VITALITY.

Patient or Guardian's Name *

Signature *

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Today's Date

MM / DD / YYYY