New Patient Form – Nurse Practitioner of Erie Niagara Psychiatry, PLLC

Name*

First Last Maiden

Date of Birth*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone

Cell Phone

Emergency Contact Name*

First Last

Emergency Contact Phone

Relationship to Emergency Contact

Primary Care Physician

Primary Care Physician Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Primary Care Physician Phone

Insurance Carrier

Policy Holder Name

First Last

Policy Holder Date of Birth

Pharmacy

Pharmacy Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Pharmacy Phone

Consent*

I agree to the policies below

*A 24-hour cancellation notification is required. There will be a cancellation fee charged for appointments cancelled without at least 24 business hour notice. This fee is NOT billable to any insurance carrier.
**PLEASE NOTE: You will be held liable for any collection costs and/or attorney fees in the event those services are needed to collect this debt.
*** By signing this form you are indicating that you have read and understand the accompanying office policy.

NEW PATIENT INFORMATION FORM