The Emily Program - Registration Form

Get help with Eating Concerns

Is the patient age 18 or older? **

New Patient Registration

Patient Legal Name* *

First Name

Last Name*

Last Name

Preferred Name

Legal Sex*

Patient's Date of Birth*

Address*

Street Address

Street Address Line 2

City

Postal / Zip Code

State

Email Address*

If under 18 years of age, enter guardian email address.

Phone Number*

Format: +1 (000) 000-0000.

Were you referred by a healthcare provider?*

Referring Provider First Name

Referring Provider Last Name

Referring Provider Agency*

Referring Provider Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Type of Referring Provider

Emergency Contact

Emergency Contact Name

First Name

Last Name

Emergency Contact Relationship

Address

Street Address

Street Address Line 2

City

Postal / Zip Code

State

Emergency Contact Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Legal Guardian

Legal Guardian Name*

First Name

Last Name*

Last Name

Are you an Emergency Contact*

Legal Guardian Address*

Street Address

Street Address Line 2

City

Postal / Zip Code

State

Legal Guardian Primary Phone*

Format: +1 (000) 000-0000.

Relationship to Patient*

Additional Legal Guardian Name

First Name

Last Name

Financial Information

Please Select a Financial Plan*

Policy Number/ID*

Insurance Plan Name*

Group Number/ID*

Subscriber Relationship to Client*

Subscriber Name*

First name

Last Name

Subscriber Date of Birth

Date

Insurance Phone Number

Benefits & Eligibility or Member Services Phone NumberFormat: (000) 000-0000.

Secondary Insurance Plan Name

Secondary Insurance Policy Number/ID

Secondary Insurance Group Number/ID

Secondary Insurance Subscriber Name

First Name

Last Name

Secondary Insurance Subscriber Date of Birth

Date

Secondary Insurance Phone Number

Benefits & Eligibility or Member Services Phone NumberFormat: (000) 000-0000.

Additional Information

Preferred Office Location **

Indicate your current time zone*

How did you hear about us?*

LIINE LOCATION

Liine First Name

Liine Last Name

Liine Email

Liine Phone

Format: +1 (000) 000-0000.

PHONE CONDITION

LIINE WHISPER

Brand

Form Name

How did you hear about us?

Form Callback Number

Oops! It looks like the phone number you input is invalid. Please input a valid phone number in order to submit.

By submitting this form and signing up for texts, you consent to receive text messages related to scheduling your appointment from The Emily Program at the number provided, and agree that any associated call(s) may be recorded for quality and training purposes. This form and any subsequent communications via email or text are not intended for exchanging protected health information and will only be used to respond to your inquiry for more information about our program and services. We disclaim all warranties with respect to the security and privacy of any information submitted through this form or exchanged via text message or email. You also expressly agree to our Privacy Policy and Web Submission Terms. Message and frequency varies. Message and data rates may apply. Text STOP to cancel and HELP for help.