Patient Intake

Patient Intake - Opioid or Alcohol Abuse

APPLE RIDGE TREATMENT CENTER
Welcome to Evergreen Medicine. Our goal is to help you with your recovery from opioid and/or alcohol abuse. We offer two programs in the office. One, an oral treatment called Suboxone film. Second, a once a month intramuscular injection called Vivitrol. Please fill out the following forms in their entirety. Once submitted, a cooridinater will call you to set up your appointment.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Social Security Number
Email*

Confirmation Emailexample@example.com
Phone Number*

Area CodePhone Number
Valid Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Patient Intake - Opioid or Alcohol Abuse