Appointment/Consultation Request

Please complete the following form.

We will get back to you as soon as we can.

Thank you for your patience.

Michael Rimm MD
Gabrielle Galler-Rimm MD

Patient Information and Appointment Request

"*" indicates required fields

Patient Name*

First Middle Last

Patient Date of Birth*

Patient Age*

Patient Sex*

Marital Status*

Patient Mailing Address*

Street Address Address Line 2 City State ZIP Code

Primary Phone*

Responsible Party*

Relation to Patient*

Patient or Parent E-mail Address*

Referred By*

Primary Care Doctor*

Do you have a prior or current Psychiatrist/Therapist/School Counsellor?*

Yes

No

Name of prior or current Psychiatrist/Therapist/School Counsellor*

Last appointment attended*

How long with this prior provider?*

Current Medications?

Main Concerns (how long occurring?)*