Self-Referred Intake Form

PATIENT DEMOGRAPHIC INFORMATION

Name

Phone

DO YOU HAVE A PRIMARY CARE PHYSICIAN?

Yes, I have a primary care physician No, I do not have a primary physician and am self-referred.

**IF YOU ANSWERED YES TO THE ABOVE, FILL OUT THE PRIMARY CARE PHYSICIAN INFORMATION BELOW**

Name of Physician

Practice Speciality

Practice Address

Practice Phone

Practice Email

Practice Fax

INSURANCE INFORMATION

Insurance Name

Insurance Number

Reson for Consultation

Don't Let Chronic Insomnia Steal Your Joy: (678) 928-9700

Our providers will walk the journey with you from start to finish.