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216-752-9090

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New Patient Forms

First Visit?

First time visiting? Be sure to fill out the forms below. You can fax them over to 216-752-9080, print & scan, or bring them in on your first visit.

I plan to self-pay

I plan to use Tricare

I plan to use Medicare, Medicaid, or Commercial insurance

I plan to pursue Spravato Treatment

Self-Pay

Informed Consent Form - Part 1

Informed Consent Form - Part 2 - Screening Questionnaire

Patient Health Questionnaire

Billing and Payment Agreement

Tricare

Informed Consent Form - Part 1

Informed Consent Form - Part 2 - Screening Questionnaire

Patient Health Questionnaire

Medicare, Medicaid, or Commercial

Adult TMS Registration

TMS Therapy Exclusion Criteria

Medication Checklist

Consent to Release Information

TMS Patient Consent

HIPPA Notice

HAM-D

New Patient Referral Form

Spravato

Spravato Patient Enrollment Form

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Book a Free Consultation