Midwest Recovery and Wellness

Intake Form

Client Registration

 

Registration

  • Please leave the name, birthdate, address and phone number of your spouse/significant other/parents (if applicable).
  • Please list any medications.
  • Please list the names and ages of others living in your household.
  • Please leave an emergency contact.
  • Enter Name of Patient or Authorized Representative Agreeing to the above terms.
  • Drop files here or
    Max. file size: 256 MB, Max. files: 2.
      PLEASE UPLOAD FRONT AND BACK OF YOUR INSURANCE CARD
    • Drop files here or
      Max. file size: 256 MB, Max. files: 2.
        PLEASE UPLOAD FRONT AND BACK OF YOUR INSURANCE CARD