Dr. Jennifer Keith- New Patient Forms

If you are a New Patient, please either print and complete the appropriate forms from the list or complete the electronic form below after you have read the appropriate forms for your service.  If you have questions about the information in the forms, please contact Dr. Keith to discuss your concerns prior to the first appointment.

New Patient Information

Your Full Name (First, Middle, Last):

Mailing Address:

Phone Number:

Is it ok to leave a message?
YesNo

Email address

Sex:
MaleFemale

Marital Status:
SingleMarriedDivorcedWidowed

Date of Birth:

Age:

Employer:

Position:

Referred by:

May I contact this person?
YesNo

Have you been in therapy before?
YesNo

For your current problem?
YesNo

If so, where and when?

Emergency Contact

Name:

Relationship:

Phone:

Responsible Party/Spouse/Parent Information

Name:

Date of Birth:

Phone:

Primary Care Physician Information

Name:

Phone:

Address:

How long have you been a patient of this physician?

For purposes of continuity of care, may we contact your physician to let him/her know of your visit?
YesNo

If yes, I give permission to Dr. Keith to send a general statement notifying my primary care physician of my visit today. The information sent will be used for coordination of care, and will be limited to a brief description of the problem area and/or diagnosis, and a general outline of treatment.

Please sign and date (electronically) below to agree to Dr. Keith's terms
of service as outlined in the service agreement forms.

Check here if you accept Dr. Keith's terms.

Check here to acknowledge that you have read and understand the
Georgia HIPAA Notice.