EmailMeForm
NEW PATIENT REGISTRATION
Vitality Psychiatry Group Practice
Treatment Request
*
Please select
Psychiatric Evaluation and Medication
MeRT or TMS
Our therapists are not accepting any new patients at the moment.
Name
*
First
Middle
Last
Date of Birth
*
MM
/
DD
/
YYYY
Phone
*
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Email
*
Sex
Please select
Male
Female
Required by the pharmacies, what appears on the birth certificate
Address
*
Street Address
City
State / Province / Region
Postal / Zip Code
Insurance Company
Member ID Number
Group Number
Primary Policyholder’s Name
Insurance Card (front)
*
May use credit card if paying private, go to ccauth.vpgp.org to fill out credit card authorization form
Insurance Card (back)
*
Back of credit card if paying private
Picture ID
*
driver or state license, passport, parent's ID
Credit Card
Card Number
Expiration
MM
/
YY
CVV
What is this?
3 or 4 digit number printed on the back/front of your credit card
Protected in vault
Data collected via fields that have our security seal are encrypted and stored with the highest global security standard — PCI compliance. Your data is absolutely safe in Vault.
Credit Card Billing Address
Street Address
City
State / Province / Region
Postal / Zip Code
If different from home address
Signature
Clear
I authorize Vitality to store my credit/debit card information and automatically charge my credit/debit card for payments related to treatment
Emergency Contact Name
*
First
Last
Relationship
Please select
Parent
Grandparent
Legal Guardian
Spouse
Sibling
Child
Friend
Inlaw
Phone
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Allergy
Height (ft in)
*
Weight (lbs)
*
Surgical History
appendectomy, tonsillectomy
Medical History
asthma, migraine, hypertension, etc
Psychiatric History
depression, anxiety, adhd, bipolar, etc
Current Medications
Past Antidepressants used
prozac, lexapro, abilify, lithium, lamictal
Family Psychiatric History
mom-depression, brother-adhd
Addiction History
opiates, alcohol, cannabis, nicotine, detox and rehabilitation
Legal/Arrest History
Primary Care Physician and/or Additional Therapist/Psychiatrist
Pharmacy name, address, and phone number
Checkbox
Low or Sad Mood
Difficulty Concentrating
Difficulty with Appetite
Increased Anxiety
Decreased Energy
Feelings of Loss or Guilt
Suicidal Thoughts
Thoughts Others are Out to Harm You
Panic Symptoms
Decrease or Excessive Sleep
Experiencing Nightmares
Headaches and/or Body Aches
Lost Interest in Activities
Hearing Voices
Strange Visual Experiences
Irritability or Mood Swings
Other symptoms or concerns
