New Patient Form

Name(Required)
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Birth Gender(Required)
Mailing Address(Required)
Do you authorize us to leave a message?(Required)
Race(Required)
Ethnicity(Required)

Emergency Contact

Contact Name(Required)

Preferred Pharmacy

Primary Medical Insurance (Please bring these cards with you on your appt date as well)

Max. file size: 256 MB.
Max. file size: 256 MB.
Max. file size: 256 MB.
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Patient Relationship to insured(Required)
Max. file size: 256 MB.
Max. file size: 256 MB.
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Patient Relationship to insured

New Patient Information and Consent

Authorization for Release of information

May we leave testing results or referral info in email or voicemail?(Required)

Patient Consent for Treatment

1. I voluntarily consent to any and all health care treatment and diagnostic procedures provided by Sayana Medical and its associated physicians, clinicians and other personnel. I am aware that the practice of medicine and other health care professions is not an exact science and I further state that I understand that no guarantee has been or can be made as to the results of the treatments or examinations at Sayana Medical.

2. I agree to be contacted via email or SMS with information related to my visit, like: a patient portal invitation, post-visit satisfaction survey, appointment or checkup reminders, health tips, or new services that relate to me or my family.

3. I consent to the use and disclosure of my/the patient’s protected health information for purposes of obtaining payment for services rendered to me/the patient, treatment and health care operations consistent with Sayana Medical & Wellness Center Notice of Privacy Practices.

4. I authorize payment of medical benefits to Sayana Medical and Wellness Center.

5. I give permission to obtain all my medication/prescription history when using an electronic system to prescriptions for my medical treatment.

6. We require a 48-hour business notice to cancel or reschedule any appointments, a fee of $50 will be charged to the card on file if not cancelled within the policy.

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New Patient Form will be submitted to Sayana Medical Spa and Wellness Center