Earthman Psychiatry New Patient Request Form

Earthman Psychiatry New Patient Form

Name*

Phone*

Email*

Street Address*

City

State

Postal code*

Date of Birth*

Behavioral Health Insurance Provider (at times this is separate from your major medical insurance provider and can be found on the back of your insurance card).

Feel free to upload your insurance card (front & back) here, or enter the information below*

Insurnace Card Information:

ID Number

Group Number

Provider Contact Number

Have you been hospitalized for any psychiatric reasons in the past 5 years?

Are you applying for disability of FMLA?

Have you had any suicide attempts in the past 5 years?

Please be aware that we have a 3-business day cancelation Policy. If you need to cancel or reschedule any current appointment we ask that you call at least 3 business days in advance to allow us to offer that appointment time to another patient. If you miss / reschedule with less than a 3-business day notice you are subject to a cancelation fee of $100 for the initial appointment, and $50 for follow-up appointments. appointments *

Dr Earthman requires you complete a Medical/Psychiatric History Form prior to your Initial New Patient appointment with him. If you cannot complete the form online, we ask to you arrive at least 30 minutes prior to your scheduled appointment time appointment to complete it. Dr Earthman will not be able to see you without a completed form and you will be subject to a cancelation/reschedule fee. *

I consent to Dr Earthman reviewing my prescription medication history online prior to my first appointment. *

Signature

Date*

I Consent to Receive SMS Notifications from Dr Earthman's office regarding my appointments and communications about my care. Feel free to call or text our office at (512) 528-9498 if you ever need assistance. You can reply STOP to unsubscribe at any time.

Cedar Park TMS

Brian S. Earthman, MD, is a psychiatrist and addiction medicine specialist focusing on adult mental health and substance abuse treatment. Dedicated to ensuring patients experience whole health after treatment, Dr. Earthman’s goal is to guide patients to wellness using a comprehensive treatment approach that includes TMS, medication, counseling, and Alpha-Stim™ therapy. He has been certified and trained by the Clinical TMS Society (CTMSS) since 2018. Dr. Earthman graduated from the University of Texas at Austin, receiving a bachelor’s degree in biology. He then attended Texas Tech School of Medicine, where he received his medical degree. Dr. Earthman completed his residency in the department of psychiatry at the University of Texas Health Science Center in San Antonio in 2005. He is also a diplomat of the American Board of Addiction Medicine.

Cedar Park TMS

11901 W Parmer Ln
#310 B
Cedar Park, TX 78613

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Phone : (512) 265-0429

Earthman Psychiatry New Patient Request Form

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