New Application

Jul , 27 , 2020 Admin

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Step 1 of 4 - General Information

NAME*
First Last
D.O.B.:*
MM slash DD slash YYYY
CLICK HERE TO UPLOAD YOUR PICTURE ID CARD (no selfies)
Max. file size: 5 GB.
ACCEPTABLE FORMS OF ID: DRIVER LICENSE, FLORIDA ID
CLICK HERE TO UPLOAD ADDITIONAL DOCUMENTS
Max. file size: 100 MB.
Proof of Residence
HOME ADDRESS*
Street Address Address Line 2 City State ZIP Code
EMAIL
Enter Email Confirm Email
MOBILE PHONE NUMBER*
NAME PRIMARY PHYSICIAN
First Last
Primary Physician Phone
PHARMACY NAME AND ADDRESS*
Street Address Address Line 2 City State ZIP Code
PHARMACY PHONE*
EMERGENCY CONTACT*
First Last
EMERGENCY PHONE*
CURRENT MEDICATIONS PRESCRIBED*
HAVE YOU EVER BEEN DIAGNOSED WITH A PSYCHIATRIC DISORDER? PLEASE DESCRIBE:*
PLEASE PROVIDE ANY OTHER PERTINENT INFORMATION REGARDING YOUR ADDICTION ISSUES OR ANY MAJOR LIFE EVENTS CURRENTLY CONTRIBUTING TO YOUR ADDICTION (TRAUMA,ABUSE,DEATH/ILLNESS,ETC.)*

DO YOU HAVE A MEDICAL HISTORY OF CHRONIC PAIN? DID CONTRIBUTED TO YOUR ADDICTION?*
WHO SUGGESTED THAT YOU SEEK THERAPY?*
WHEN DID YOU START USING ILLEGAL DRUGS? AGE?*
UNTIL NOW, WHAT HAS PREVENTED YOU FROM RECEIVING HELP WITH YOUR ADDICTION ISSUE?*
IS YOUR FAMILY AWARE AND SUPPORTIVE OF YOUR DESIRE TO DETOXIFY?*
WHAT OTHER DRUGS ARE YOU CURRENTLY USING, OR HAVE YOU ABUSE IN THE PAST?*
HAVE YOU EVER BEEN INVOLVED IN A 12 STEPS PROGRAM OR OTHER TYPE OF COUNSELING?*
HAVE YOU PREVIOUSLY UNDERGONE ADDICTION TREATMENT?*
WHAT WAS THE LONGEST LENGTH OF TIME YOU HAVE REMAINED SOBER AFTER TREATMENT?*
HOW DID YOU FIND OUT ABOUT OUR FACILITIES?*

DATE:*
MM slash DD slash YYYY
FULL NAME*
First Last
CONSENT*
I agree to the privacy policy.
I have received a copy of the Privacy Notice, Treatment Guide and Authorization for Release Form.I understand that a copy of the current Privacy Notice is posted in the Waiting Room.I will also obtain a copy of any future amended Privacy Notice or the Treatment Guide.
SIGNATURE*

DATE*
MM slash DD slash YYYY
FULL NAME*
First Last
EMAIL
Enter Email Confirm Email
CONSENT*
I agree to this agreement.
I understand that detoxification, complete titration from Buprenorphine and an improvement in my quality of life are the goals of this program.

I realize that all medications have potential side effects. Buprenorphine and other medications may produce dependency, addiction, respiratory depression, drowsiness, changes in mood, anxiety, or mental clouding. I will report any such side effects to the physician and office immediately.

In the event of a need to discontinue taking these medications, I will first consult with the doctor and strictly follow their instructions for the safe tapering down of my medications. Failure to do so may result in severe withdrawal effects and possibly even death. I understand that even with the tapering process there may be some discomfort or withdrawal effects.

I agree to be on time to all my scheduled appointments.

I agree to adhere to the payment policy outlined by the office.

I agree not to conduct any improper of disruptive activity while in the office.

I understand the risks, side effects, and benefits of these medications and they have been discussed with me in detail.

I understand that Buprenorphine and/or other medications may impair the mental and/or physical abilities required for the performance of potentially hazardous tasks such as driving a car or operating machinery.

I understand that I should not take other drugs such as tranquilizers, sedatives or antihistamines without first consulting with the physician. I understand that I should not use alcohol. The combination of Buprenorphine, Methadone, other drugs, alcohol and/or opioids may produce dangerously profound effects such as sedation, respiratory depression, blood pressure, and severe physical pain.

I will not attempt to get controlled substances from other health care provider without telling them that I am taking Buprenorphine and/or medications prescribed by the Doctor. I understand it is against the law to do so and will lead to the discontinuance of my medical treatment at this facility and possible further legal consequences.

I will not use any illegal controlled substances, including cocaine, etc.

I agree to random urine drug tests to assess my compliance.

I will not share, sell or trade my medication for money, goods or services. I understand this is illegal and will result in my termination from the program and possible further legal consequences.

I will safeguard my medication from loss or theft. If I lose or misplace my prescription, I will be without my prescribed medication until my next scheduled visit.

I am responsible for taking the medication in the dose prescribed. I will not raise the dose without the doctor's prior approval. If I do so, it may cause an overdose and it may lead to running out of my medication before my next appointment. Visits will be scheduled not earlier than 7 days and no later than 21 days and are required for management of the medications. Refills will be prescribed only on this schedule basis.

I understand that A New Day Medical strongly recommends that I seek addiction counseling either through personal sessions with a therapist or with organized support groups such as Narcotics Anonymous. We will supply you with a list of counselors and/or support groups in your area. I understand that my chances of remaining sober and avoiding relapse are much higher if I address the mental aspects of my addiction, and establish a strong support network.

All female patients must notify the physician if they are pregnant or possibly plan on becoming pregnant. If you are pregnant, you should not take Suboxone/Zubsolv.

I understand that violations of any of the above may be grounds for termination of treatment.
Doctor and Patient agree that this Agreement is essential to the Doctor's ability to treat the Patient's addiction effectively and that failure of the Patient to abide by the terms of the Agreement will result in the withdrawal of all prescribed medication by the Doctor and termination of the Doctor/patient relationship.
SIGNATURE*
First Last
NOTICE
Under Florida law, physicians are generally required to carry medical malpractice insurance or otherwise demonstrate financial responsibility to cover potential claims for medical malpractice. However, certain part-time physicians who meet state requirements are exempt from the financial responsibility law. YOUR DOCTOR MEETS THESE REQUIREMENTS AND HAS DECIDED NOT TO CARRY MEDICAL MALPRACTICE INSURANCE. This notice is provided pursuant to Florida Law.

New Application

New Application

Step 1 of 4 - General Information

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