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Easy Appointment Tab

FBH NEW PATIENT APPOINTMENT FORM

Fill in the NEW PATIENT APPOINTMENT FORM to start your journey now.

Patient Name i.e. Person Who Needs The Appointment(Please Give The Required Info.)
Type Birthdate of Patient Or Click Calendar Icon >>>>>>>(Please Give The Required Info.)
Please type if Is the patient Male or Female. (Please Give The Required Info.)
For prompt service please read & answer all questions carefully e.g. your best contact number and times you can be reached or exact name of your HMO. Thank you!
Please include your best contact #'s and times staff can reach you.
What is your concern?(Please Give The Required Info.)
TYPE OF SERVICE REQUESTED (Please Give The Required Info.)
Is this your first Consultation with Dr. Parvin or FBH Team member. Yes/No.(Please Give The Required Info.)
Do you have a Family Member in the practice currently or the past? Please write down their full name. Otherwise please answer "No." (Please Give The Required Info.)
Name of Parent, Guardian or Power of Attorney of Patient. Please type self if this an adult new patient request. (Please Give The Required Info.)
Has the person seeking treatment been recently discharged from the hospital or with in the last year? YES/NO Please explain if Yes. (Please Give The Required Info.)
Does the person seeking treatment have a pending court or legal case, custody evaluation or wanting a one time evaluation? YES/NO Please explain in detail if Yes. (Please Give The Required Info.)
Has the person seeking treatment received substance treatment i.e. admission or program or actively abusing substances? YES/NO Please explain if Yes. (Please Give The Required Info.)
Has the person seeking treatment had recent or past history of "Self Injury Behavior?" YES/NO Please explain if Yes. (Please Give The Required Info.)
Has the person seeking treatment ever attempted or had ideas of suicide or homicide ever? YES/NO Please explain if Yes i.e. Date & Severity e.g. needing hospital treatment etc... (Please Give The Required Info.)
Has the person seeking treatment ever been convicted of a sex offender crime? YES/NO Please explain if Yes. (Please Give The Required Info.)
Is the person seeking treatment wanting to transfer care to FBH i.e. change their doctor or therapist? YES/NO Please explain if Yes. (Please Give The Required Info.)
Guarantor’s Valid home Address including town/city & zip code. Thanks! ! ! (Please Give The Required Info.)
Guarantor's Email(valid email required)
Guarantor's Home TELEPHONE # best contact # & times staff can reach you.(Please Give The Required Info.)
Guarantor's MOBILE # best contact # & times staff can reach you.(Please Give The Required Info.)
Employer Name & Telephone Number(Please Give The Required Info.)
We accept Self Pay or Exact Insurance e.g. BCBS PPO or BCBS HMO (please type NAME OF HMO)
Please write Self Pay or Exact Insurance e.g. BCBS PPO or (Please type NAME of HMO)(Please Give The Required Info.)
Insurance Group # if any(Please Give The Required Info.)
Insurance ID # if any(Please Give The Required Info.)
Your Secondary Insurance Group# & ID# Type "NA" for not applicable if you do not have one.(Please Give The Required Info.)
Customer Service telephone number on the back of your Insurance Card (Please Give The Required Info.)
The FBH POLICIES (see "ABOUT US PAGE"): Please write Yes I agree with the FBH Policies to be able to schedule appointment(s)! Thank you :-) (Please Give The Required Info.)
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