Kel Health & Wellness

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(626) 768-2649

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New Patient Forms

All of the forms that are labeled under “New Patient Packet” must be filled out completely, in order to be able to schedule your first appointment.

If you have any questions or issues on any of the forms, please contact us at (626) 768-2649 or email info@kelhealthandwellness.com. We respond to every message as quickly as possible during the week.

New Patient Form
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    Patient Information

    Preferred Pharmacy(Optional)

    INSURANCE INFORMATION

    PRIMARY INSURANCE

    INSURANCE INFORMATION

    SECONDARY INSURANCE

    AS PATIENT, OR AS LEGAL GUARDIAN OF MINOR PATIENT, I AGREE TO PAY FOR ALL SERVICES RENDERED. THIS OFFICE MAY BILL MY INSURANCE CARRIER AS NEEDED. I AM FINANCIALLY RESPONSIBLE FOR ALL NON-COVERED SERVICES. I AUTHORIZE THIS OFFICE TO RELEASE MY INFORMATION TO PROCESS ANY REQUESTS.

    Generalized Anxiety Disorder (Anxiety Assessment)

    Over the last 2 weeks, how often have you been bothered by the following problems?
    Not At All
    Several Days
    More Than Half Days
    Nearly Half Days
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    Patient Health Questionnaire (Depression Assessment)

    Over the last 2 weeks, how often have you been bothered by any of the following problems?
    Not At All
    Several Days
    More Than Half The Days
    Nearly Half A Days
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    PTSD Checklist 5 (PCL-5)

    Stressful life experiences. How much you have been bothered by that problem IN THE LAST MONTH.
    Not At All
    Several Days
    More Than Half Days
    Nearly Half A Days
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    Credit Card Information

    Terms & Conditions of Kel Health And Wellness
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