Appointment Request - Elara Health

New Patient Appointment Request Form

We are currently accepting new patients for virtual appointments in Massachusetts and Nevada. Note that this form is for new patients only. Existing patients should schedule using the Charm patient health portal
Patient's Legal Name*

First NameLast Name
In which state are you requesting an appointment?*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Format: (000) 000-0000.
E-mail*
example@example.com
Sex at Birth*
Date of Birth*

MonthDayYear
Date
YesNo
Parent/Legal Guardian Name

First NameLast Name
Parent/Legal Guardian Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Legal Guardian Email Address
example@example.com
What is your insurance plan?*
We are currently unable to accept any MassHealth plans.
Briefly describe what led you to seek care and how we can help*
Scheduling Availability: please provide some days or times that work best for scheduling an initial intake appointment. Evening and weekend options are available for your convenience.*
Please upload a copy of the FRONT and BACK of your insurance card*

Please provide this information even if you do not plan on using insurance, as we'll sometimes need this information to verify prescription drug coverage.
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Please upload a copy of a photo ID (license, state ID card, passport, passport card)*

After submitting this form, we will verify your insurance eligibility through our billing partner, Alma. By submitting this form, you give us permission to submit your insurance information to our billing partner solely for the purposes of insurance verification. Your information will always be kept secure, and you will not be billed or charged for any fees as part of this verification process.
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How did you hear about Elara Health?*
Should be Empty:

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New Patient Appointment Request Form

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