Lifeline Psychiatry
(770) 458-0450
contact@gapsychiatry.com
2150 Peachford Rd. Suite K Atlanta, GA 30338
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Release of Information Form
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HIPAA Form
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History Form
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CONTACT
HOME
ABOUT US
SERVICES
TMS Therapy
Inpatient Services
Outpatient Services
SPRAVATO (ESKETAMINE) / KETAMINE THERAPY
STAFF
PATIENTS
DIAGNOSES
MEDICATIONS
RESEARCH
Current Clinical Studies
PATIENT FORMS
Release of Information Form
Clinic Policies Form
HIPAA Form
Demographics Form
History Form
BLOGS
CONTACT
Book An Appointment
MAKE A PAYMENT
Demographics Form
Home
Demographics Form
PATIENT INFORMATION
Name
*
First
Middle
Last
Birth Date
*
MM slash DD slash YYYY
Gender:
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Female
Address
*
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Home Phone #
*
Mobile #
*
E-mail
*
Employment Status
*
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Employed Part-time
Unemployed
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Student
School and/or Employer
Grade
Ethnicity
*
Religion
*
Marital Status
*
FINANCIAL INFORMATION
Name of the person responsible for payments (Fill the details below)
Name
*
First
Middle
Last
Relationship to Patient
*
Gender
*
Male
Female
Address
*
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Phone #
*
Email
*
OTHER CONTACT INFORMATION (if applicable)
Emergency Contact:
*
Name
*
First
FAMILY CONTACTS (Check one if applicable)
Biological Parent(s)
Adopted Parent(s)
Foster Parent(s)
Guardian(s)
Case worker
Name
*
First
Phone
*
Name
*
First
Phone
*
I understand that I am responsible for making complete payments at the time of service and hereby authorize Lifeline Psychiatry LLC to use necessary individual and credit card information on file to process payments.
I was given the opportunity to review the privacy practices and clinic policies and I consent for treatment by Suneel Katragadda, MD and other providers working at Lifeline Psychiatry LLC.
PATIENT / GUARDIAN SIGNATURE
*
Date
*
MM slash DD slash YYYY
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