MyO2 Health | SimplePractice

Who would be receiving care?

My partner and me

Someone else

Your info

First name

Last name

Phone

Name you go by

Date of birth

Gender

State

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Reason for care

What is the reason for seeking care?

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Administrative

Referral source

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Client Preferences

Is there anything that the practitioner needs to know?

For example: what you'd like to focus on, insurance or payment questions, etc.

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Prefered Practitioner and Location for follow up Visits

Your initial consultation will be via telehealth. Follow up appointments can be in person or telehealth. Leslie's office is in Westbrook and Heidi's is in Saco. Please choose the practitioner closest to you if you have a preference.

If you or others are in immediate danger or experiencing a medical emergency, call 911 immediately.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice.