NEW PATIENT APPT REQUEST FORM SUBMISSIONS

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Let's get started!* This field is required.What would you like to do today?
Reschedule an Appointment (I am an existing patient)
Enroll in Treatment (I am a new patient)
Re-start Treatment (I have not been to Ideal Option for 6 weeks or more)
2
Have you completed at least one appointment at Ideal Option in the last 6 weeks?If you select YES, please be sure to click SUBMIT to access the rescheduling tool.
YESNO
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What type of substance use do you need treatment for?* This field is required.
Heroin
Alcohol
Methamphetamine
Benzodiazepines
Fentanyl
Pain Pills
Multiple Substances
Other
4
If you are seeking treatment for alcohol withdrawal:

Treatment for alcohol withdrawal must be started on a Monday so we can see you daily for 4-5 days after you begin to taper.

If you choose to schedule your first appointment on a different day of the week, your provider will use that time to complete your assessment, however, you must visit the clinic in person on the following Monday to get a blood alcohol content (BAC) test and receive your prescription for medication.

For your safety, your provider will advise you to continue drinking as normal until you start your medication in order to prevent potentially dangerous withdrawal symptoms.
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If you are currently drinking, do you have a responsible adult who can drive you to your first appointment and assist you during the first week of treatment?* This field is required.If you select NO, a nurse will be contacting you to discuss your situation and determine if you can safely manage withdrawal at home by yourself.
YES
NO
I am not currently drinking / have started treatment elsewhere
6
What state do you live in? * This field is required.If your state is not listed, we apologize but we are not licensed to provide services to you at this time.
Alaska
Alaska
Arkansas
Idaho
Maryland
Montana
New Mexico
North Dakota
Oregon
Washington
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What is your street address? Providing an address will help your pharmacy process your prescription with fewer delays. If you don't have a permanent address, please leave blank.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
8
What is your zip code?* This field is required.We will schedule your appointment at the clinic closest to this zip code.
9
What is your full name?* This field is required.
First Name
Last Name
10
Are you currently enrolled in school?
Yes, I am a part time student
Yes, I am a full time student
No, I am not enrolled in school
11
What is your marital status?
Married
Single
Divorced
Domestic Partner
Separated
Widowed
12
What sex is listed on your state ID or driver's license?* This field is required.We are required to ask this question for insurance verification purposes.
Female (F)
Male (M)
Other/Unknown (X)
13
If female, are you currently pregnant? Pregnant women are welcome at Ideal Option. We ask this question to ensure pregnant women are given priority with scheduling.
YESNO
14
What is your date of birth?* This field is required.
MM/DD/YYYY
15
What is your best phone number for calling or texting?* This field is required.We won't be able to schedule your appointment without a valid phone number.
16
What is your email?* This field is required.We won't be able to schedule your appointment without a valid email address.
example@example.com
17
What date would you prefer for your appointment?* This field is required.We cannot guarantee same-day appointment requests using this online form. If you would like to be seen today, please call 1-877-522-1275.
Preferred Date
Month
Day
Year
18
What time of day would you prefer for your appointment?* This field is required.
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2
3
4
5
6
7
8
9
10
11
12
Hour
00
15
30
45
Minutes
AM
AM
PM
19
What type of health insurance do you have?* This field is required.
Medicaid
Commercial
Medicare
Uninsured
Other
20
What is the name of your insurance plan? * This field is required.We won't be able to schedule your appointment until we have your health insurance information. If you don't have insurance, please enter "uninsured" and a financial counselor will contact you to discuss your options.
21
What is the membership ID for your insurance plan?* This field is required.Please provide your membership ID we can verify your insurance coverage.
22
What is your social security number?* This field is required.Please provide your SSN so we can verify your insurance. All data is encrypted and stored securely.
###-##-####
23
How would you prefer we reach you to confirm your appointment?* This field is required.By selecting an option, you are giving consent for Ideal Option to contact you using your preferred method.
text message
phone
email
24
Is it okay for Ideal Option to leave a voicemail on the phone number provided?
YESNO
25
Is there anything you want to share with us? (optional)Please share any information that will help us give you the best care possible.
Huge
Large
Normal
Small
Ok
Ok
26
How did you hear about Ideal Option?* This field is required.
Facebook / Google
Community / Social Services
Online Search
Primary Care Provider
Friend / Family
Word of Mouth
Emergency Medical / Hospital
Ideal Option Peer
Other
27
Notice of Privacy Practices* This field is required.Please review the Notice of Privacy Practices (NOPP) found at the bottom of this page, and then check the box.
28
Financial & Treatment Responsibility* This field is required.By clicking the "I AGREE" checkbox, you also indicate that you accept financial responsibility, if any, for the Ideal Option services you receive. We may verify your insurance benefits and may submit a claim to your health insurer for payment. Without waiving your financial responsibility, you agree to assign your right to medical benefits to Ideal Option. If your health insurer does not pay your claim, or only pays a portion of your claim, you agree to pay the remaining charges. I authorize Ideal Option, PLLC to disclose to any third-party payor all necessary information and relevant portions of my patient record for the purpose of receiving payment for services rendered
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Tags
AMANDA
CHELSI
COURTNEY
Action
DONE
NS
Info
SCHEDULED
DUPLICATE
IN PROGRESS
KATELYN
CHEYENNE
SHAREN
NO PROFILE
RESTART
KIM
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