New Patient Registration

New Patient Form

Please complete this form before your first scheduled appointment. It only takes a few minutes, and we can check your insurance benefits, copays, and coverage before your first visit. If you have any questions, call our office at 804-751-8644.
Patient Name *

First Name Middle Name Last Name Suffix
Parent / Guardian Name (if patient is a minor)

First Name Middle Name Last Name Suffix
Date of Appointment

Month Day Year
Date
Name of Your Clinician *

John Dwyer, PhD, Licensed Clinical Psychologist Melissa Findlay, LCSW, Licensed Clinical Social Worker David Epstein, PsyD, Licensed Clinical Psychologist Elizabeth Novak, LCSW, Licensed Clinical Social Worker Jill Sexton-Newton, LPC, Licensed Professional Counselor No one chosen yet
Age
Patient Date of Birth *

Month Day Year
Date
Gender

Male Female
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email *
example@example.com
Primary Phone Number (cell) *

Area Code Phone Number
Please note that our Telemed services only work with cell phones or email.
Alternate Phone Number

Area Code Phone Number
What methods may we use to contact you? (Check all that apply.)

Primary phone Alternate phone Email
Primary Insurance Information
Primary Insurance Company Name
Member / Subscriber ID
Group Number
Who is the insurance subscriber?

Patient Mother Father Other
If the patient is not the subscriber, subscriber's name and date of birth.
For patients with Aetna HCA only, please provide subscriber social security number
Aetna HCA uses United Healthcare and Aetna subscriber ID will not transfer
Secondary Insurance Information
Does the patient have a secondary / supplemental insurance policy?

No Yes
Secondary Insurance Company Name
Member / Subscriber ID
Group Number
Check if you receive disability benefits?

Yes, I receive disability benefits.
Who will be responsible for payment of this account? Please note you may not sign for someone else. This is typically the patient or the parent/guardian who brings the patient for treatment *

First Name Middle Name Last Name Suffix
Primary Care Provider
May we contact the Primary Care Provider for coordination of care?

Yes No I do not have a PCP
Please review the following documents:
I have reviewed the HIPAA Privacy Practices and Policies and the Office Policies and Procedures. I agree to treatment for myself or my child. If using insurance, I also agree that insurance may be billed and payment made to The Meridian Group and / or specific clinician seen for services rendered. *

Yes
Signature (use mouse, finger tap or digital pen)

Clear
Please type name her for signature above.
Signature indicates agreement with Office Policies and Procedures
Should be Empty:

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New Patient Form

Primary Insurance Information

Secondary Insurance Information