Request First Visit - Pembroke Center for Wellness

Request Your First Visit

Start Your Journey Towards Mental Wellness

Information and Instructions

We strive to make your first visit as seamless as possible. For in-office appointments (preferred for new patients) or telehealth follow-ups, please bring a valid ID and the signed treatment consent form. A $25 deposit is required to secure your first visit, which will be applied to your copay or refunded if there is no patient responsibility.

First Visit Request Form

Complete the sections below as accurately as possible.

Patient Information

Patient's Name

Patient's Email

Patient's Phone

Home Phone

Patient's Date of Birth

Patient's Gender

Address

Referring Provider/Entity:

Primary Care Provider Name

Address

Insurance Information

The following insurance information is optional. However, if you provide this information, we are able to authorize their plan and get them seen more quickly.

Primary Insurance Name:

Primary Insurance ID #

Insurance Group #

Secondary Insurance Name

Secondary Insurance Group #

Secondary Insurance ID #

Emergency contact name

Relationship

Phone

Please upload your ID and Insurance card

ID Card (Driver's License or Other) Upload (Front and Back)

Primary Insurance Card Upload (Front and Back)

Secondary Insurance Card Upload (Front and Back)

Other files Upload