Healing Hope Mental Health Clinic

PATIENT INFORMATION

Full Name

First Name

Last Name

Date of Birth

Gender

Male

Female

Phone

Email

Address

City

State/Province

Zip/Postal

APPOINTMENT DETAILS

Are you a new or returning patient?

Yes

No

Reason for Appointment:

Preferred Method of Consultation

INSURANCE AND PAYMENT INFORMATION

Insurance Provider

Insurance Policy Number

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Payment Method

MEDICAL HISTORY (PRIMARILY FOR NEW PATIENTS)

Current Medications

Allergies

Previous Diagnoses

Primary Care Physician

EMERGENCY CONTACT INFORMATION

Name (Full name of emergency contact)

First Name

Last Name

Relationship to Patient

Emergency contact's primary phone number

CONSENT AND POLICIES

Consent to Services: Acknowledgment that services will be provided virtually or in-person.

Privacy Policy Agreement: Confirmation that the patient has read and agrees to the clinic's privacy practices.

Cancellation Policy: Acknowledgment of the clinic's cancellation or rescheduling policies.

Additional Comments or Questions

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