Interested in becoming a new patient?

Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Gender *

Male

Female

Other

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Substance Use History (check all that apply) *

Amphetamines / Speed / Meth

Barbiturates / Downers

Opiates / Pain Medications

Cocaine

Cannabis / Marijuana

Tobacco

Vaping

Alcohol

Benzodiazepines (Xanax, etc)

Psychedelics (LSD, Ecstasy, Bath Salts)

None of these

Have you been on Suboxone / Methadone treatment within the past year? *

No

Yes

Which day would you prefer? *

Monday

Tuesday

Wednesday

First Available

Would you prefer morning or afternoon? *

Morning Appointment

Afternoon Appointment

First Available