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 Outpatient 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
3
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
Which of the following medications are you interested in?* This field is required.Ideal Option does not offer methadone but we can help patients transition from methadone to buprenorphine.
Suboxone (oral buprenorphine)
Brixadi (injectable buprenorphine)
Sublocade (injectable buprenorphine)
Vivitrol (injectable naltrexone)
Oral Naltrexone
Withdrawal Medications
I Don't Know
Other
5
If you are currently drinking, can you get to the clinic for your first visit safely and legally?* This field is required.If you arrive at the clinic over the legal blood alcohol limit, we cannot knowingly allow you to drive yourself home. Please ensure you have a driver or another way to get to and from the clinic for your first visit.
YES, I will arrange for a responsible adult to drive me to the clinic
NO, I have no way to get to the clinic without drinking and driving
I am not currently drinking / I 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
Eastern Washington
Western 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
Which Alaska clinic is most convenient for you to visit?* This field is required.We'll try our hardest to get you scheduled at the clinic you select.
Alaska
Anchorage
Fairbanks
Kenai
Wasilla
10
Are there any other Alaska clinics you'd be able to visit?In the event your desired clinic is full, we can get you scheduled at any clinics you select below. Please select all that apply.
Anchorage
Fairbanks
Kenai
Wasilla
11
Which Arkansas clinic is most convenient for you to visit?* This field is required.We'll try our hardest to get you scheduled at the clinic you select.
Bentonville
Conway
Fayetteville
Fort Smith
Hot Springs
Jacksonville
Jonesboro
Little Rock
Paragould
Russellville
Van Buren
12
Are there any other Arkansas clinics you'd be able to visit?In the event your desired clinic is full, we can get you scheduled at any clinics you select below. Please select all that apply.
Bentonville
Conway
Fayetteville
Fort Smith
Hot Springs
Jacksonville
Jonesboro
Little Rock
Paragould
Russellville
Van Buren
Other
13
Which Eastern Washington clinic is most convenient for you to visit?* This field is required.We'll try our hardest to get you scheduled at the clinic you select.
Kennewick
Pullman
Spokane 5th Ave
Spokane Francis
Spokane Valley
Walla Walla
Wenatchee
Yakima
14
Are there any other Eastern Washington clinics you'd be able to visit?In the event your desired clinic is full, we can get you scheduled at any clinics you select below. Please select all that apply.
Kennewick
Pullman
Spokane 5th Ave
Spokane Francis
Spokane Valley
Walla Walla
Wenatchee
Yakima
Other
15
Which Idaho clinic is most convenient for you to visit?* This field is required.We'll try our hardest to get you scheduled at the clinic you select.
Boise
Caldwell
Coeur d'Alene
Idaho Falls
Kellogg
Lewiston
Pocatello
Sandpoint
16
Are there any other Idaho clinics you'd be able to visit?In the event your desired clinic is full, we can get you scheduled at any clinics you select below. Please select all that apply.
Boise
Caldwell
Coeur d'Alene
Idaho Falls
Kellogg
Lewiston
Pocatello
Sandpoint
Other
17
Which Maryland clinic is most convenient for you to visit?* This field is required.We'll try our hardest to get you scheduled at the clinic you select.
Catonsville
Cumberland
Frederick
Hagerstown
Waldorf
18
Are there any other Maryland clinics you'd be able to visit?In the event your desired clinic is full, we can get you scheduled at any clinics you select below. Please select all that apply.
Catonsville
Cumberland
Frederick
Hagerstown
Waldorf
Other
19
Which Montana clinic is most convenient for you to visit?* This field is required.We'll try our hardest to get you scheduled at the clinic you select.
Billings
Bozeman
Butte
Cut Bank
Glasgow
Great Falls
Helena
Kalispell
Missoula
20
Are there any other Montana clinics you'd be able to visit?In the event your desired clinic is full, we can get you scheduled at any clinics you select below. Please select all that apply.
Billings
Bozeman
Butte
Cut Bank
Glasgow
Great Falls
Helena
Kalispell
Missoula
Other
21
Which North Dakota clinic is most convenient for you to visit?* This field is required.We'll try our hardest to get you scheduled at the clinic you select.
Bismarck
Fargo
Grand Forks
Minot
Williston
22
Are there any other North Dakota clinics you'd be able to visit?In the event your desired clinic is full, we can get you scheduled at any clinics you select below. Please select all that apply.
Bismarck
Fargo
Grand Forks
Minot
Williston
Other
23
Which New Mexico clinic is most convenient for you to visit?* This field is required.We'll try our hardest to get you scheduled at the clinic you select.
Albuquerque Encino
Albuquerque Osuna
Farmington
Las Cruces
Rio Rancho
24
Are there any other New Mexico clinics you'd be able to visit?In the event your desired clinic is full, we can get you scheduled at any clinics you select below. Please select all that apply.
Albuquerque Encino
Albuquerque Osuna
Farmington
Las Cruces
Rio Rancho
Other
25
Which Oregon clinic is most convenient for you to visit?* This field is required.We'll try our hardest to get you scheduled at the clinic you select.
Albany
Bend
Corvallis
Eugene
Hillsboro
Redmond
Salem
Springfield
26
Are there any other Oregon clinics you'd be able to visit?In the event your desired clinic is full, we can get you scheduled at any clinics you select below. Please select all that apply.
Albany
Bend
Corvallis
Eugene
Hillsboro
Redmond
Salem
Springfield
Other
27
Which Western Washington clinic is most convenient for you to visit?* This field is required.We'll try our hardest to get you scheduled at the clinic you select.
Arlington
Auburn
Bellevue
Bellingham
Edmonds
Everett
Longview
Maple Falls
Marysville
Monroe
Mt. Vernon
Northgate
Olympia
Puyallup
Renton
Tacoma
Vancouver
28
Are there any other Western Washington clinics you'd be able to visit?In the event your desired clinic is full, we can get you scheduled at any clinics you select below. Please select all that apply.
Arlington
Auburn
Bellevue
Bellingham
Edmonds
Everett
Longview
Maple Falls
Marysville
Monroe
Mt. Vernon
Northgate
Olympia
Puyallup
Renton
Tacoma
Vancouver
Other
29
What is your full name?* This field is required.
First Name
Last Name
30
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
31
What is your marital status?
Married
Single
Divorced
Domestic Partner
Separated
Widowed
32
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)
33
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
34
What is your date of birth?* This field is required.
MM/DD/YYYY
35
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.
36
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
37
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
38
What time of day would you prefer for your appointment?* This field is required.
1
2
3
4
5
6
7
8
9
10
11
12
Hour
00
15
30
45
Minutes
PM
AM
PM
39
What type of health insurance do you have?* This field is required.
Medicaid
Commercial
Medicare
Uninsured
Other
40
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.
41
What is the membership ID for your insurance plan?* This field is required.Please provide your membership ID we can verify your insurance coverage.
42
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.
###-##-####
43
Is it okay for Ideal Option to leave a voicemail on the phone number provided? * This field is required.
YESNO
44
Is it okay for Ideal Option to send text messages to the phone number provided?* This field is required.Messages will include appointment reminders and scheduling questions. You can unsubscribe at any time.
YESNO
45
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
46
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
47
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.
48
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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1st Choice Clinic
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2nd Choice Clinic
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