vortexpsychiatry.com - Prospective Patient Form

Prospective Patient Form
In preparation for your first visit with Said A. Ibrahimi, M.D., Vortex Psychiatry, we will need some information.

Once we have verified your insurance benefits, a member of our staff will contact you as soon as possible to schedule your appointment. Please complete the information below
Patient Name

First Name Last Name
Patient Date of Birth

Month Day Year
Date
Patient Email
example@example.com
Patient Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Best Contact Phone Number
Please enter a valid phone number.
Other contact phone number
Please enter a valid phone number.
Leave message on voicemail

Yes No
Leave message with person(s)

Yes No
Person name to leave message:
IF MINOR:
Parent/Guardian Name

First Name Last Name
Parent/Guardian (Complete address, if differs from above)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Best Contact Phone Number
Please enter a valid phone number.
Other contact phone number
Please enter a valid phone number.
If MINOR: Does the patient live with both parents?

Yes No
If not, is there a custody order?
Patient Email
example@example.com
Brief Reason for Appointment:
Who were you referred by?
Insurance Provider :

(if applicable)
Insurance Name
Insurance ID# (Please include any letters):
Insurance Group number, Local number
Please include Mental Health/Provider Services Phone Number:(Can be found on front or back of insurance ID card)
Please enter a valid phone number.
Should be Empty:

Prospective Patient Form

IF MINOR:

Insurance Provider :