Tele Med Clinix Forms

New Patient Forms

Tele Med Clinix New Patient Form

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Release of Confidential Information

Two Way Authorization Consent For Release of Confidential Information. This release allows your previous provider to share your records with our clinic.

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Need to upload your driver's license or Insurance ID Card? you can do so here!

Two Way Authorization Consent

This release of confidential information allows our medical team share your records with our counseling team.

Treatment Forms

Vivitrol Treatment Informed Consent

Consent form for Naltrexone Intramuscular Treatment.

Sublocade Maintenance Treatment

Intake Questionnaire for Patient Treatment-Planning.

Sublocade Treatment Agreement

buprenorphine extended-release injection treatment agreement.

Consent to treatment of child.

Authorization to consent to medical treatment of a child.

Buprenorphine | Naloxone Treatment Agreement

Buprenorphine | Naloxone Treatment Agreement

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