NEW PATIENT INTAKE 

PATIENT INFORMATION

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Appointment Reminders:
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SOCIAL HISTORY

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Employment Status
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CURRENT BEHAVIORAL HEALTH STATUS

Are you experiencing any of the following?

FAMILY HISTORY

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MEDICAL HISTORY

Do you have/had any of the conditions listed below:

MEDICATIONS/PHARMACY INFO

INSURANCE INFORMATION

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ALLERGIES

OTHER HEALTH INFO

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by typing your name above, you are signing this document electronically.

Thanks for submitting! Your information has been sent to Life Healing Center, PC. Please call us at 678-344-8268 with any questions.

Please note you will still need to sign treatment consent and office policy acknowledgements when you arrive to the office.  These forms are available for review under our Patient Info tab on this site. 

 

You will also need to provide a copy of your ID and insurance card at time of service along with any copays that are due.