Heritage Health & Wellness

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    Patient Information

    Preferred Pharmacy

    INSURANCE INFORMATION

    PRIMARY INSURANCE

    INSURANCE INFORMATION

    SECONDARY INSURANCE

    AS PATIENT, OR AS LEGAL GUARDIAN OF MINOR PATIENT, I AGREE TO PAY FOR ALL SERVICES RENDERED. THIS OFFICE MAY BILL MY INSURANCE CARRIER AS NEEDED. I AM FINANCIALLY RESPONSIBLE FOR ALL NON-COVERED SERVICES. I AUTHORIZE THIS OFFICE TO RELEASE MY INFORMATION TO PROCESS ANY REQUESTS.

    Generalized Anxiety Disorder (Anxiety Assessment)

    Over the last 2 weeks, how often have you been bothered by the following problems?
    Not At All
    Several Days
    More Than Half The Days
    Nearly Half A Days
    0
    1
    2
    3
    0
    1
    2
    3
    0
    1
    2
    3
    0
    1
    2
    3
    0
    1
    2
    3
    0
    1
    2
    3
    0
    1
    2
    3

    Patient Health Questionnaire (Depression Assessment)

    Over the last 2 weeks, how often have you been bothered by any of the following problems?
    Not At All
    Several Days
    More Than Half The Days
    Nearly Half A Days
    0
    1
    2
    3
    0
    1
    2
    3
    0
    1
    2
    3
    0
    1
    2
    3
    0
    1
    2
    3
    0
    1
    2
    3
    0
    1
    2
    3
    0
    1
    2
    3
    0
    1
    2
    3
    0
    1
    2
    3

    Credit Card Information

    Terms & Conditions of Kel Health And Wellness
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