Atlantic Wish Clinic: Integrative Health & Wellness Services

Contact Us

Name:

Email:

Phone:

Address: include city, state, and zip code

What's your insurance, if any

For what condition would you like our specialist physician to evaluate and treat?

Did anyone refer you? If yes, please provide the name & phone number

How did you find our office?

May we communicate with you through phone, text, and/or email?

Emergency contact: name, contact info, & relationship to patient

Payment: self pay or insurance

I understand that by checking the box, I will Opt-In receive SMS Text, email, fax, and voice phone messages until I reply STOP to Opt-Out and that I can reply HELP at any time to receive help.

Yes

I further understand that message and data rates apply, and the SMS Text, email, fax, and voice phone message frequency will vary. Our Office utilizes a third party: RingRX Phone system (or similar product) HIPAA-compliant phone, text, video, and fax solutions for SMS Text, fax and phone calls.

Yes

I acknowledge that I have received and reviewed the Terms and Conditions and Privacy Policy provided to me in paper, electronic, verbal or website form.

Yes