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Ewing Mental Health LLC

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Patient Registration Form

Fill out and submit the form below with the correct information.

"*" indicates required fields

FIRST NAME*

MIDDLE NAME*

LAST NAME*

Date*

MM slash DD slash YYYY

GENDER*

Section Break

MARITAL STATUS

Single

Married

Divorced

Widowed

Address*

Street Address City State / Province / Region ZIP / Postal Code

PREFERRED PHONE NUMBER*

EMAIL ADDRESS*

ETHNICITY

Hispanic or Latino

Not Hispanic or Latino

Unknown/Declined

RACE

American Indian/ Alaskan Native

Asian

Black/ African American

Native Hawaiian/ Pacific Island

White

Other

Unknown/Declined

PREFFERED LANGUAGE

English

Other

Enter other preferred language

PREFFERED COMMUNICATION FOR APPOINTMENT REMINDERS

Appointment reminders are a courtesy service: all patient are responsible for remembering thier scheduled appointments. We require a minimum of 24 hour notice for cancellations

Automated Text

Automated Email

Guarantor if Not the Patient

(financially responsible party for minor or incapacitated adult

GUARANTOR NAME*

FIRST NAME LAST NAME

DATE OF BIRTH*

MM slash DD slash YYYY

RELATIONSHIP TO PATIENT

Address

Street Address City State / Province / Region ZIP / Postal Code

Note: By providing a phone number or email address, you are consenting to being contacted at that number or address regarding your treatment or billing information. In, addition your email will be used to invite you to join our secure patient portal

GUARANTOR PREFFERED PHONE NUMBER*

Home

Cell

Email*

Drivers License, Passport, Non-Drivers License. Allowed file types include: jpg, png, pdf, gif, HEIC. Maximum file size allowed: 25 MB

File

Max. file size: 256 MB.

Drivers License, Allowed file types include: jpg, png, pdf, gif, HEIC. Maximum file size allowed: 25 MB

PLEASE UPLOAD YOUR INSURANCE CARD.

Max. file size: 256 MB.

Emergency Contact Information & Relationship to Patient

NAME*

FIRST NAME LAST NAME

RELATIONSHIP

EMERGENCY CONTACT FORM*

Insurance Information

PRIMARY INSURANCE NAME*

First

EMERGENCY CONTACT PHONE*

First

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

POLICY ID NUMBER

GROUP/ PLAN NUMBER

CO-PAY $

SUBSCRIBER NAME*

FIRST NAME LAST NAME

SUBCRIBER DATE OF BIRTH

MM slash DD slash YYYY

SUBCRIBER EMPLOYER

SECONDARY INSURANCE NAME*

First Name

EMERGENCY CONTACT PHONE*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

POLICY ID NUMBER

GROUP/ PLAN NUMBER

CO-PAY $

SUBCRIBER NAME*

FIRST NAME LAST NAME

SUBSCRIBER DATE OF BIRTH

MM slash DD slash YYYY

SUBCRIBER EMPLOYER

Signature

Date

MM slash DD slash YYYY

CONSENT

The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the provider. I understand that I am financially responsible for any balance. I also authorized Healthy Mind company to release any information required to process my claims.

I give my consent

CAPTCHA

Fostering mental wellness through expert care, compassion, and individual growth.

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Quick Contact

609 439 4351
609 281 5896
100 Horizon Center Blvd, 1st and 2nd floors, Hamilton, New Jersey 08691

Office Hours

Mon | 7:30am-9:00am
Mon - Fri | 6:40pm - 8:00pm (Minus Wednesday)
Wed | 9:00 am - 7:00 pm
Sat | 9:00 am - 2:00 pm
Sundays (By Appoinment only)

Office Hours

Mon :
7:30am-9:00am

Mon - Fri :
6:40pm - 8:00pm (Minus Wednesday)

Wed :
9:00 am - 7:00 pm

Sat :
9:00 am - 2:00 pm

Sundays :
(By Appoinment only)

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Services

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