New Patient Intake Form – John Naus, MD PA

All patients requesting treatment from our office must undergo a face to face (currently telehealth only) evaluation to fully evaluate their condition and situation. Please check the box if you agree and wish to continue. *

I would like to be contacted about becoming a new patient at John Naus MD PA.

Patient Name *

First

Last

Date of birth *

Driver License

Driver License Number (This number is the 8 numbers on your state Driver License after DL) *

File Upload *

Click or drag a file to this area to upload.

Street Address *

Address Line 1

Address Line 2

City

State

Zip Code

E-mail *

Patient Phone Number *

Are you willing to accept SMS also known as TEXT messages to the above phone number? (Click YES to opt-in. Upon receiving a text, please respond with STOP to any SMS (text) to opt-out SMS (text) communication; Messaging frequency may vary; Message and data rates may apply.) (see our privacy policy: https://johnnausmdpa.com/privacy-policy/) For assistance text HELP of visit our website at johnnausmdpa.com. *

Yes
No

May we TEXT the Patient Phone Number above for purposes of scheduling, reminding you of appointments, and for general messaging through the course of your treatment? (Click YES to opt-in. Upon receiving a text, please respond with STOP to any SMS (text) to opt-out SMS (text) communication; Messaging frequency may vary; Message and data rates may apply.) (see our privacy policy: https://johnnausmdpa.com/privacy-policy/) For assistance text HELP of visit our website at johnnausmdpa.com. *

Yes
No

When is the best day/time to call you in person if necessary? Put NONE if you prefer primarily text *

Treatment Team Identification and Contact Information.

How did you find us? *

If you chose OTHER, please tell us who here.

Do you have a Doctor / PA / NP or other medical care provider we should know about? *

YES
NO

Please provide their NAME and contact phone number so that we can stay in touch (put NONE if necessary) *

First

Last

Phone

Do you have a counselor/therapist? (put NONE if appropriate) *

YES
NO

Please provide their NAME and contact phone so we can stay in touch (put NONE if necessary) *

First

Last

Phone

Please provide an email for your therapist if you have it.

Emergency Contact Information - Please only put someone down that you allow our office to contact in any case of emergency.

Name of Emergency Contact *

First

Last

Emergency Contact Phone *

Services Requested.

Are you Currently seeing or have you seen a Psychiatrist in the Past (Check all that apply.)? *

I have not ever seen a Psychiatrist
I have seen a Psychiatrist in the Past but NOT Currently
I am Currently seeing a Psychiatrist

Who was your past Psychiatrist? feel free to list more than one.

Who is your CURRENT Psychiatrist (put NONE if this does no apply to you)? *

Are you seeking disability? *

No
Yes

I understand that John Naus MD PA does not perform disability evlauations and while I may discuss with my provider any needs for short or long term disability/FMLA these concerns are handled on an individual clinical basis. *

I understand, I am not here for disability I would like a good faith evaluation and possible treatment of my condition.
I understand that this is not a disability evaluation process but I have some questions about disability and/or FLMA.
I understand but I would like a disability evaluation.

Are you seeking any type of substance/alcohol treatment? *

No
Yes

What is the primary concern that led you to request an appointment with us? (eg: ADD, Anxiety, Depression, etc.) Feel free to list more than one *

Insurance information.

Primary Insurance Carrier *

Name of "OTHER" insurance company:

File Upload (upload a picture of the FRONT of your Insurance card) *

Click or drag a file to this area to upload.

File Upload (upload a picture of the BACK of your Insurance card) *

Click or drag a file to this area to upload.

Primary Insurance Member Name *

First

Last

Primary Insurance Policy Number ( This number is very important and allows us to fully identify your insurance plan) *

Secondary Insurance Carrier *

Secondary Insurance Member Name

First

Last

Secondary Insurance Policy Number

Pharmacy Information.

Pharmacy Name *

Pharmacy Phone *

Pharmacy Fax

Pharmacy Address

Address Line 1

Address Line 2

City

State

Zip Code

Welcome to the first step to becoming a new patient!

Driver License

Treatment Team Identification and Contact Information.

Emergency Contact Information - Please only put someone down that you allow our office to contact in any case of emergency.

Services Requested.

Insurance information.

Pharmacy Information.