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New Patients Form

New Patient Forms

Fields marked with an * are required

Patient Information
Credit Card Usage Agreement
Insurance Information
Presenting Problem
Office and Financial Policies
HIPPA Privacy Notice
Information and Informed Consent for Treatment

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Protecting your private information is our priority. By visiting the HighDesertPsychiatry.com website and/or utilizing the Service, you agree to accept the practices described in our Privacy Policy and consent to the collection and use of information as discussed in our Privacy Policy and these forms.

PLEASE NOTE: There are multiple sections to complete all the forms

How did you find out about our office? *

Date *

First Name *

Last Name *

Address *

City *

US States *

Zip *

Email *

Phone

May I leave a message on your phone? *

Gender *

Birthday *

Marital Status

Social Security Number

Occupation

Education

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Emergency Contact

Emergency Contact Information

First Name *

Last Name *

Emergency Contact Phone *