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New Patient Forms

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PATIENT INFORMATION

Please select the location for your appointment
Name(Required)
MM slash DD slash YYYY
ADDRESS(Required)
MARITAL STATUS
LANGUAGE

GENDER IDENTITY

SEX AT BIRTH
ETHNICITY
RACE
Do you think of yourself as:

INSURANCE INFORMATION

MM slash DD slash YYYY
REFERRAL REQUIRED
MM slash DD slash YYYY
REFERRAL REQUIRED

PHYSICIAN INFORMATION

PHARMACY INFORMATION

ADDRESS(Required)

EMERGENCY CONTACTS

PHI Submission Notice

While CCBD will use reasonable administrative and technical safeguards when transmitting your electronic PHI in accordance with applicable law, we also realize that there are inherent risks when communicating via email. Therefore, please be aware that by choosing to send your protected health information (PHI) and related communications via email, you are agreeing to accept the risk that your PHI may be intercepted or viewed by persons with access to your email who may not be authorized to receive such information when you consent to communication through email. CCBD will not be responsible for any privacy or security breaches outside of its control that may occur through email communications that you have consented to.

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