Patient Registration Page

Fields marked * are required. Everything else helps our team prepare, and you can leave it blank. Your information is sent over an encrypted connection and kept confidential.

01About you

First name

Last name

Date of birth

Sex

Marital status

02Contact

Street address

City

State

ZIP code

Mobile phone

03Insurance

No insurance? Choose that and send the form anyway. We help you get Spravato through the manufacturer, and our fee stays $40 a session.

Do you have health insurance?

Yes, I have health insurance No, I’m uninsured right now

04Why you’re reaching out

What’s going on, in your own words?For example: “Depression for 8 years. Tried three antidepressants, only partial relief.”

05Depression and mental health history

Antidepressants you’ve tried beforeNames are enough. Rough is fine; we fill in the rest from your past prescribers.

Antidepressants you take nowWrite “None” if none.

Your depression historyHow long, and what treatment you’ve had.

Psychiatric diagnoses you’ve been given

Other psychiatric medications you’ve triedMood stabilizers, antipsychotics, anti-anxiety or ADHD medications, for example.

Mental health conditions in your familyFor example: “Mother: depression. Brother: bipolar disorder.”

Your other doctors and therapistsNames and towns, if you have them.

06How you’ve been feeling

Over the last two weeks, how often have you been bothered by the following?

07Medical history

Current medications and supplementsInclude dose if you know it, e.g. “Zoloft 100 mg daily.”

AllergiesFor example: “Penicillin: rash.” Leave blank if none.

Medical conditionsFor example: “High blood pressure since 2018.”

SurgeriesWhat, and roughly when.

08Lifestyle

Tobacco

I smoke now I used to, and quit Never

Alcohol in a typical weekFor example: “2 glasses of wine, 3 nights a week.”

Recreational substance useThis helps us keep you safe. Leave blank if none.

09Anything else

Anything else you’d like our team to know?

10Consent and signature

I have reviewed the privacy policy

Electronic signature Type your full legal name. Under the ESIGN Act this is as binding as a handwritten signature, confirms the information above is accurate, and gives your consent to receive care from PremierMD.

11How did you find us?

Register for your Spravato evaluation