CONTACT INFORMATION ADULT - Capital Mental Health LLC

Contact Information

Name*
Patient Last Name First Middle
DATE OF BIRTH*
MM slash DD slash YYYY
GENDER
Address*
Street Address City State ZIP
HOME PHONE*
CELL PHONE
PHARMACY ADDRESS / PHONE NUMBER*
REFERRED BY
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PARENT 1 NAME
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PARENT’S ADDRESS
Address
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OCCUPATION
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CELL PHONE
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PARENT 2 NAME
First
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PARENT’S ADDRESS
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OCCUPATION
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CELL PHONE
ALLERGIES*
PERSON TO NOTIFY IN AN EMERGENCY*
PHONE*
PATIENT’S EMAIL ADDRESS*
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PARENT’S EMAIL ADDRESS
PATIENT/SUBSCRIBER AUTHORIZATION STATEMENT*
- I UNDERSTAND THAT I AM RESPONSIBLE FOR PAYMENT FOR PSYCHIATRIC SERVICES RENDERED BY CAPITAL MENTAL HEALTH AT THE TIME OF MY VISIT.
  I UNDERSTAND THAT I AM RESPONSIBLE FOR THE FULL COST OF ANY APPOINTMENT I CANCELL WITH LESS THAN 24 HOURS (ONE FULL BUSINESS DAY’S) NOTICE.
  I ALLOW CAPITAL MENTAL HEALTH TO RELEASE APPROPRIATE CLINICAL INFORMATION TO MY REFERRING PHYSICIAN(S).
SIGNATURE OF PATIENT*
DATE*
MM slash DD slash YYYY
Comments
This field is for validation purposes and should be left unchanged.