Name
*
First Name
Last Name
Email
*
Phone
*
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
DOB
*
Emergency Contact Name:
Emergency Contact Phone
Emergency Contact Relationship
Who is your primary care physician?
If you are being referred by a therapist, psychiatrist, police department, probation officer, shelter, re-entry service, or hospital, please provide their name
Ok to contact you by email/phone/text/video Yes/No
Describe your opioid use history
How long you have used opioids, presription or non prescription, which drugs
When was the last time you used an opioid
Are you using an opoiod on a daily basis
Are you currently experiencing withdrawal symptoms
such as sweats, nausea, vomiting, diarrhea, cravings or other
Are you using other stimulants/drugs
such as alcohol, cocaine, meth, hallucinogens, marijuana or other drugs
What other medical conditions do you have
Describe other medical conditions not listed above (if applicable)
List any other prescription medications you are currently taking
What are your goals and expectations for treatment/services?
Have you every used or been prescribed suboxone or buprenorphine
Any other information you would like to share?
Date
MM
DD
YYYY
By typing my name in this box I am agreeing to share this information with Dr Marvin Riske MD and Redemption Medical and authorize Dr Riske and Redemption Medical to contact me via email/phone/text/video call. I understand that this form is for informational purposes only and does not establish a doctor-patient relationship.
