Carencia New Patient Form

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Carencia New Patient Form
FROM THE CARENCIA TEAM

THANK YOU FOR YOUR INTEREST IN BECOMING A PATIENT

We have recently updated our new patient experience and related forms, please click on the Carencia image below to be taken to our website. Once on the websites, follow the “Get Started” prompts to complete the intake process.
patient safety agreement*

Carencia does not review your submissions right away. If you are having thoughts of hurting yourself or are worried about someone’s safety please call 911 or the national crisis hotline at 988 https://988lifeline.org

Medical History

Please list all the medications and supplements you currently take, including the dose, instructions, and the reason for taking.
ARE YOU CURRENTLY TAKING ANY MEDICATIONS AND/OR SUPPLEMENTS?*

YesNo
Current Medications/supplements*
DO YOU HAVE ANY DRUG ALLERGIES?*

YesNo
Drug Allergies*
HAVE YOU BEEN DIAGNOSED WITH A MEDICAL ILLNESS AND/OR HAVE MEDICAL CONDITIONS?*

YesNo
Medical Illnesses*

Substance Use History
DO YOU HAVE ANY CURRENT MISUSE, ABUSE, OR DEPENDENCE OF SUBSTANCES?*

YesNo
DO YOU HAVE ANY PREVIOUS MISUSE, ABUSE, OR DEPENDENCE OF SUBSTANCES?*

YesNo
Please List Substance History*
HAVE YOU HAD ANY TREATMENT FOR SUBSTANCE USE?*

YesNo
TREATMENT FOR SUBSTANCE USE*

Financial Information
AN HONEST APPROACH TO BILLING & FEES

Finances can be a subject that medical practices avoid discussing. At Carencia, our financial transparency is a point of pride. We know that the intersection of financial realities and empathy is complicated, logistically and emotionally, so we’ve chosen to address this dilemma directly.

How Carencia Uses Your Financial Information:

Your card will not be charged today. Carencia securely stores your encrypted payment information, and we will only charge your card on file in the event of a late cancellation or missed appointment. For more information regarding our policies, please refer to our financial agreement. If you do not see a charge on your card for a missed appointment or late cancellation, please expect a request for payment at your next visit.

Carenica's Stance on Missed & Canceled Appointments:

We understand that late cancels and missed appointments can occur for many reasons, but the way in which they impact us goes beyond economics. It also means we’ve missed an opportunity to assist another patient during that same time. It’s our sincere hope that you understand our perspective.
Authorization*

By submitting this form, I authorize Carencia, LLC. to charge my credit card in the future for any transactions deemed necessary by the provider. I confirm that I have read and agree to Carencia's Financial Consent Agreement in its entirety.
ACKNOWLEGEMENTS*

I understand that no-shows or cancellations within 24 hours of appointment time will still be charged to card on file.

My Products

New Patient Registration$0.50

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Patient Signature*

Clear
Guardian Signature*

Clear
Indvidual Completing Form Signature*

Clear
Should be Empty:

	Morning	Afternoon	Evening	All Day
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday

	None (None at all)	Slight (Rare, Less than a day or two)	Mild (Several Days)	Moderate (More than half the days)	Severe (Nearly Every Day)
Little interest or pleasure in doing things?
Feeling down, depressed, or hopeless?
Feeling more irritated, grouchy, or angry than usual?
Sleeping less than usual, but still have a lot of energy?
Starting more projects than usual or doing more risky things than usual?
Feeling nervous, anxious, frightened, worried, or on edge?
Feeling panic or being frightened?
Avoiding situations that make you anxious?
Unexplained aches and pains?
Feeling that your illnesses are not being taken seriously enough?
Thoughts of actually hurting yourself?
Hearing things other people couldn't hear such as voices even when no one was around?
Feeling that someone could hear your thoughts, or that you could hear what another person was thinking?
Problems with sleep that affect your sleep quality overall?
Problems with memory (e.g. learning new information) or location (e.g. finding your way home)?
Unpleasant thoughts urges, or images that repeatedly enter your mind?
Feeling driven to perform certain behaviors or mental acts over and over again?
Feeling detached or distant from yourself, your body, your physical surroundings, or your memories?
Not knowing who you really are or what you want out of life?
Not feeling close to other people or enjoying your relationships with them?
Drinking at least 4 drinks daily of any kind of alcohol in a single day?

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Carencia New Patient Form

Service and Provider Preferences

Patient Questionnaire

Appointment Preferences

Patient Information

Guardian/Guarantor Information

Employment Information

Insurance Information

Emergency Contact Information

Pharmacy

Symptom Questionnaire

Medical History

Treatment Hstory

Substance Use History

Acknowledgements

Financial Information