New Patient Form

Fill out your paperwork here after you make an appointment with us!

First name*

Last name*

Birthday*

Month

Day

Year

Phone*

Email*

Address*

Gender*

SSN*

Marital Status

Married

Single

Long-term Relationship

Divorced/SeparatedDivorced/Separated

Times Married

How many children do you have and the their ages?

Who currently resides in home with you?

Do you have family nearby?

Level of Education

High School Dropout

High School Diploma/GED

Associate's Degree

Bachelor's Degree

Master's Degree

Doctorate

Are you currently employed? If yes, what do you do and how long have you been in current position?

Source of Referral: e.g. online or from a friend*

Emergency Contact and phone number*

I have read and understood Buprenorphine Consent to Treatment Form (can be found on our website)*

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I read and understood fee schedule (can be found on our website)*

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There is no refund

Failure to meet my payment obligation could result in an interruption of my prescription refills or be deemed willing to enter into a “civilized withdraw” from my treatment. Such directive was given to Forever Well by the State of Tennessee Office of Licensure during our annual inspection.

Signature*

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Forever Well

Phone :615-375-1188

Fax: 615-375-1290

foreverwelldickson@gmail.com

118 Highway 70 East Unit #1

Dickson TN 37055

Accessibility Statement

Terms & Conditions

Refund Policy

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