New Patient Form

New Patient Information

HIPAA Secure
Full Name *

First Name Last Name
Date of Birth *

Month Day Year
Date of Birth
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Phone Number *
E-mail *
Insurance Company (We don't accept Medicare or Medicaid products such as UPMC for You or UPMC for Life) *
Insurance Member ID *
Please describe in brief what you are struggling with and any experiences with medication *
How did you hear about us?
BY FILLING OUT THIS SECURE FORM YOU ARE ALLOWING US TO CONTACT YOU BY ENCRYPTED EMAIL OR PHONE.

You will receive a secure email message from info@dradamtripp.com providing instructions to set up an appointment for your first visit with us or providing you with contact information on local providers better able to meet your needs.

This process may take up to 1 week. Please check your spam folder if you are not seeing that email.

For completion of any short term disability paperwork, FMLA paperwork, school accomodations, patients need to have been seen for at least 90 days, not at the initial visit. All paperwork will completed at an office visit, and require an office visit for completion. We do not perform consultations or court mandated assessments.
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New Patient Information