(800) 681-3114

New Client Information for Dr. Abrams

This form is to be completed by the individual seeking care from Dr. Abrams; if that individual is under the age of 18, the form needs to be completed by the parent or guardian

Please do not fill this out until you are asked to

*Name: *Email:
*Address:
Occupation: City/State/Zip:
Work Phone: -- Home Phone: --
Cell Phone: *SS#:
Date Of Birth: Referred By:
Insurance Company:
Plan#: Group#:
Name Of Insured: Secondary Insurance:
Plan#: Group#:
Are you currently under the care of a physician or taking medications? (if so please list medication and prescribed medications)
I understand that all conversations and communications with Dr. Abrams are confidential except for reports of child abuse and threats of violence against a specific individual. Dr. Abrams will keep all of my records secure and confidential. I give Dr. Abrams permission to bill my insurance carrier for services he has provided to me. Should these payments come to me, I understand that they are due to Dr. Abrams. I understand that Dr. Abrams requires 24 hours’ notice to cancel an appointment, I agree to pay $50.00 if I fail to provide this.