Exam

What do we call you?*

How can we stay connected*

How tall are you?*

How much do you weigh?*

Date of Birth (DOB)

Where are you located?

Active Ingredients*

Read the list of opiates and check off any that apply to you.

Please list any other drugs

How are you taking these drugs?*

Oral

IV

Nasal

Payment Options*

I Fully Have The Means To Pay For My Own Treatment.

I Would Consider A Payment Plan for My Rapid Detox Under Sedation.

I Have No Way To Pay For Treatment Regardless How Effective This Method.

Rapid Detox Under Sedation (In-Patient Treatment itself) is typically not covered by Medical Insurance.

We have several financing options that we will discuss during our initial phone call.

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New Patient Self-Assessment