Do I qualify for suboxone?

1

How do you identify?Select the option that applies most to you

Male

Female

Other

2

Have you ever been or are you currently prescribed suboxone?

YESNO

3

How often do you use opiates or other drugs?

Daily

Weekly

Monthly

4

Do you have medical insurance?If you do not have medical insurance but qualify for it, our team may still be able to help.

YESNO

5

Are you now, or do you experience withdrawal when you do not use opiates and other drugs?

YESNO

6

What is your current opiate of choice?If you do not currently use opiates, please select "Not applicable"

Heroin

Fentanyl

Methadone

Prescription Opiates

None / Not applicable

Other

7

Do you use alcohol or benzodiazepines?

Alcohol

Benzodiazepines

Both Alcohol and Benzodiazepines

Neither / Not applicable

8

Have you ever been a patient at a detox or residential treatment center?

YESNO

9

It sounds like Suboxone could be a good fit for your recovery treatment!

A member of our patient care team will be in contact with you soon to schedule your first appointment.

10

Before we can book your appointmentWe need just a little bit more information

11

Name

First Name

Last Name

12

Email

example@example.com

13

Phone Number

Please enter a valid phone number.

14

Suboxone might not be the best fit for your recovery treatment, but there are other options!

A member of our patient care team will reach out to you soon to answer questions and provide information!