New Patient Inquiry Form – Required of all prospective patients

Note 1: Our New Patient Inquiry Form must be downloaded, completed, and returned to our office using the instructions below before we'll be able to welcome you as a Restoration Healthcare patient.

Note 2: Please read our General FAQs and our Health Insurance FAQs before downloading and beginning work on your New Patient Inquiry Form. Making sure we’re the right fit for you and your healthcare includes reviewing the health insurance plans we accept at Restoration Healthcare.

Instructions

(Please follow the below instructions for accessing, filling out, and returning your New Patient Inquiry Form)

  1. Download the New Patient Inquiry Form by right-clicking on the image to the right (below for mobile) and selecting "Save Link As."
  2. Save the file in a private and secure location on your computer. When saving, please place your last name at the beginning of the file name example: if your last name is Smith — "Smith_RH_New_Patient_Inquiry.pdf")
  3. For best results, please use the latest version of Adobe Reader to open and work on your New Patient Inquiry Form. (Mac users: While it is possible to work on this file using the Preview program on your Mac, it is NOT advisable. Please use Adobe Reader instead.)
  4. Please Type all of your responses — DO NOT HANDWRITE your responses.
  5. Once all questions on the one-page form are answered, please save the PDF file one last time, and then attach the file to a new email message that you send to:

    [email protected]

Important: Type "New Patient Inquiry for (place your last name here)" in the subject line of your email message (e.g., New Patient Inquiry for Smith), along with the following information in the body of the email message itself:

"The attached New Patient Inquiry Form is from (insert your first and last name here). My phone number is (insert your phone number here). Please review my New Patient Inquiry Form and then let me know the timeframe for getting back in touch about the next step in becoming a patient at Restoration Healthcare.)"