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 NUMBER*
REFERRED BY
PARENT 1 NAME
PARENT’S ADDRESS
Address
OCCUPATION
CELL PHONE
PARENT 2 NAME
First
PARENT’S ADDRESS
OCCUPATION
CELL PHONE
ALLERGIES*
PERSON TO NOTIFY IN AN EMERGENCY*
PHONE*
PATIENT’S EMAIL ADDRESS*
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
Name
This field is for validation purposes and should be left unchanged.