Order Number
** All information on this form will remain confidential , secure, and encrypted via HIPAA compliance
Title
Choose One
Mr.
Ms.
Mrs.
Prof.
Dr.
First Name
*
Last Name
*
Email Address
*
Contact Number
*
Alternate Contact Number
Do you have a place to live? If so, where?
*
Do you own your own car?
*
Employment Status
*
Unemployed, Full Time, Part Time etc
Which program are you interested in?
*
Methadone
Suboxone
Onyx
Please refer to the program page on our website for more information.
Do you have anxiety or depression?
Are you taking benzodiazepines? If so, which ones?
*
Date of Birth
*
Insurance Information
*
Name of insurance provider & policy #
Brief Summary of Usage History:
*
What are you taking, how often, for how long, and last use
How did you hear about us?
From a Friend
Internet
Referral from MD
Other
Information Summary
Web Site
** All information on this form will remain confidential , secure, and encrypted via HIPAA compliance
Title
Choose One
Mr.
Ms.
Mrs.
Prof.
Dr.
First Name
*
Last Name
*
Email Address
*
Contact Number
*
Alternate Contact Number
Do you have a place to live? If so, where?
*
Do you own your own car?
*
Employment Status
*
Unemployed, Full Time, Part Time etc
Which program are you interested in?
*
Methadone
Suboxone
Onyx
Please refer to the program page on our website for more information.
Do you have anxiety or depression?
Are you taking benzodiazepines? If so, which ones?
*
Date of Birth
*
Insurance Information
*
Name of insurance provider & policy #
Brief Summary of Usage History:
*
What are you taking, how often, for how long, and last use
How did you hear about us?
From a Friend
Internet
Referral from MD
Other
Information Summary