Intake Form

HIPAA Consent *

I consent to Cascade Neuropsychology possessing my protected health information for the purpose of providing services

I consent

Name *

Patient name

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Home Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone Number *

Main phone number

(###)

###

####

SMS Opt In

By checking this box, you agree to receive text messages regarding scheduling, customer care, and security alerts from Cascade Neuropsychology. You may reply STOP to opt-out at any time. Reply HELP for assistance. Message and data rates may apply. Messaging frequency will vary. Please check our SMS Terms of Service page for more information.

Yes

No