Name: Sacred Psychiatric
Address: San Diego, CA, 92102, US
Telephone: 858-251-7370

New-Patient-Intake-Form

Patient-Intake-Form

Step 1 of 4

PLEASE PRINT AND COMPLETE ALL ENTRIES
Name:*
DOB:*
Phone
Email*
Address*
Street Address City State / Province / Region ZIP / Postal Code Country
Emergency Contact Name:*
Relationship to Patient:*
Emergency Contact Phone:
Allergies:*
What are you seeking care for?*
Are you currently taking any psychiatric medications? If so, please list all:*
Have you previously taken any psychiatric medications? If so, please list all past psychiatric medications:*
Do you have any medical conditions? If so please list:*
*Please upload a valid photo ID here:*
Accepted file types: jpg, png, pdf, Max. file size: 2 MB.
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Date-yes
MM slash DD slash YYYY

PAYMENT
Full name on card:*
Card type*
Card number:*
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Date-today
MM slash DD slash YYYY
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Expire Date*
MM slash DD slash YYYY
Expire Date*
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Expire Date
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Expire Date
MM slash DD slash YYYY
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3 digit security code:*
Upload Front of Credit Card
Accepted file types: jpg, png, pdf, Max. file size: 2 MB.
Upload Back of Credit Card
Accepted file types: jpg, png, pdf, Max. file size: 2 MB.
Card Zip code:*
Is this a HSA or FSA card:*
Our office requires that a debit/credit card be kept on file for payment of any co-payment, co- insurance, deductible, or charge that may not be covered by your health insurance or if you are paying out of pocket . This form will be kept confidential and only authorized staff has access to the information.
I acknowledge and authorize Sacred Psychiatric to charge the above credit card account for any co-payment, co-insurance, deductible and/or charges not covered by my health insurance provider.
I acknowledge that my card will be run in the event payment is not received within thirty days after I receive a statement.
I agree to receive billing statements, invoices and receipts via the email I have provided to this office.
If I am an uninsured patient I authorize payment at time of service. I agree to update any information regarding this credit card account.
I authorize this card to be charged in the event that I no show or have a late cancellation that is not due to an extenuating circumstance.
Cardholder name:*
Cardholder signature
Date*
MM slash DD slash YYYY
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- By providing your phone number and clicking "Submit," you agree to receive text messages from Sacred Psychiatric regarding appointment reminders, order updates, and account notifications. Messaging frequency may vary. Standard message and data rates may apply. Reply "STOP" at any time to opt out or "HELP" for assistance. View our Privacy Policy and Terms & Conditions for more details.
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