Iron IV Referrals - New Patient Information

This form collects and stores Personal Health Information. All information is sent and stored in encrypted format. Our technology vendor has signed a HIPPA Business Associate contract to ensure they comply with all HIPPA rules to protect your health information.

Please review our HIPPA Security Policy at Specialty Natural Medicine by clicking here for more information on how your personal health information is protected.

Specialty Natural Medicine requires all new patients to provide new patient information via this online form. If you do not wish to use this form, please contact us immediately to cancel your new patient appointment.
Do you consent to have your New Patient information securely transmitted and stored with Specialty Natural Medicine and our HIPPA compliant technology vendors? *

Yes, I consent to having Specialty Natural Medicine and it's HIPAA compliant vendors securely transmitting and storing my personal health information.

Medical Insurance varies greatly between policies and providers. Please contact your insurance company directly to confirm benefits before your appointment. Specialty Natural Medicine and its representatives can let you know which insurances we are contracted with, but cannot guarantee or offer guidance on specific coverage of individual plans. Please bring in your medical insurance card(s) and your drivers license (or ID) to your first appointment so we can copy for our records.
Primary Medical Insurance *
Primary Insurance Member ID *
Is the Patient the Subscriber to Primary Medical Insurance *

Yes No
Name and Birthdate of Primary Subscriber *
Will we be billing Secondary Insurance? *

Yes No
Secondary Medical Insurance *
Secondary Insurance Member ID *
Name and Birth Date of Secondary Subscriber *

Please click submit below or back if you need to edit any information prior to submission.

Note that you MUST click submit for us to receive your information.
Should be Empty:

Patient Demographics