New Client - Patient Access - Twin Health and Wellness Center (Form 1A)

Please use the online form...
* = Required Information

Date
(Auto Filled) Date
(Auto Filled) / MM / DD YYYY
Personal Info
Patient Name Patient Name * First Last
Phone Number Phone Number * - ### - ### ####
Email *
Referred By *

Referred By Employee Social Media Community Partners
Employee Name
If you chose Employee (Referred By) *
Please select the services needed
(Select ALL that apply) *

Please select the services needed
(Select ALL that apply) General Medical Services Sexual Transmitted Diseases Education, testing, treatment Food Assistance Transportation Assistance Other medical services Other medical services
Do you have health insurance? *

Do you have health insurance? Yes No
Attach a picture of your Drivers License / ID Card:

Attach Files
Attach a picture of your Health Insurance Card:
(Front Of Card)

Attach Files
Attach a picture of your Health Insurance Card:
(Back Of Card)

Attach Files
Consent of sharing basic info with THWC employees and providers of care. *

Consent of sharing basic info with THWC employees and providers of care. Yes No
Draw your signature into the box below. *

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.