Shopping CartYour Cart is EmptyQuantity: RemoveSubtotalTaxesShippingTotalThere was an error with PayPalClick here to try againThank you for your business!You should be receiving an order confirmation from Paypal shortly.Exit Shopping Cart Izzy Health PLLC Toggle NavigationWelcomeServicesContactChevronPatient Registration WelcomeServicesContactChevronPatient Registration PATIENT REGISTRATION Symptoms*Patient's Last Name*Patient's First Name*Patient's Middle InitialPatient's Mailing Address*Phone Number (Home, Work, Cell)*Patient's Date of Birth (MM/DD/YYYY)*Patient's GenderMFPatient's Marital StatusPatient's RacePatient's EthnicityPatient's Preferred LanguagePatient's Email AddressResponsible Party's Last NameResponsible Party's First NameResponsible Party's Middle InititalResponsible Party's Mailing AddressStreet Address, City, State, ZipPhone Number (Home, Work, Cell)Date of Birth (MM/DD/YYYY)Responsible Party's GenderMFResponsible Party's Marital StatusResponsible Party's Relationship to PatientInsuranceInsurance Policy Holder's Subscriber ID#Insurance Policy Holder's Group#Insurance Policy Holder's Last NameInsurance Policy Holder's First NameInsurance Policy Holder's Middle InitialInsurance Policy Holder's Date of Birth (MM/DD/YYYY)Insurance Policy Holder's GenderMFInsurance Policy Holder's Marital StatusInsurance Policy Holder's Relationship to PatientEmergency Contact Full Name*Emergency Contact Phone #*Emergency Contact Relationship to Patient*In case of an emergency, do we have permission to contact the person listed above?*YesNoI certify that the information provided above is completed and accurate to the best of my knowledge*YesSignature of Patient/Patient Representative*Full NameDate*CONSENT FOR TREATMENT OF AN ADULT (Printed Name of Client/Legal Representative)*I hereby authorize Izzy Health PLLC to conduct evaluations, diagnosis, treatment, and/or psychological testing based on the professional recommendations of my psychiatrist. I understand that such procedures provided by Izzy Health PLLC psychiatrists or ancillary staff would be subject to my agreement. CONSENT FOR TREATMENT OF AN ADULT (Witness Date)*CONSENT FOR TREATMENT OF A DEPENDENT (Printed Name of Client/Legal Representative))*I hereby certify that I am the legal guardian of this patient and legally authorize Izzy Health PLLC to provide mental health care to the above name. I am aware that such care may include evaluations, diagnosis, treatment, and/or psychological testing provided by Izzy Health PLLC psychiatrists or ancillary staff. CONSENT FOR TREATMENT OF A DEPENDENT (Witness Date)*This site uses Google reCAPTCHA technology to fight spam. Your use of reCAPTCHA is subject to Google's Privacy Policy and Terms of Service.REGISTERThank you! Your message was sent successfully. / PreviousNextPausePlayClose