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WELCOME!

If you are new to TMW Health, you are in the right place. Use the form below to provide your contact information and basic information about the care you need. We will then contact you to get any additional information based on your needs and supply access to your patient portal where you will always have access to your confidential health information 24/7.

PLEASE READ:
To receive the optimal healthcare that TMW can deliver, we highly recommend that clients COMPLETE ALL required documents. The Patient Portal Intake process can be cumbersome, but completion will increase satisfaction, efficiency, and case management while minimizing errors.

REMINDER OF CANCELLATION POLICY:
1. LATE CANCELLATION fee of $85 for failing to give at least 24-hour notice before canceling my
appointment.
2. NO-SHOW fee of $85 for failing to attend an appointment.

NEW CLIENT REGISTRATION

Please fill out the following form in order to begin your care process with The Modern Woman Health & Wellness Center. We are currently accepting new patients for early fall.

Patient First name

Preferred Name

Patient Last name

Date of Birth

Phone

Street Address

Street Address Line 2

City

Postal / Zip code

Region/State/Province

Country

If patient is a minor, please provide the following information:

Patient/Guardian First name

Parent/Guardian Last name

Relationship to Patient

Parent/Guardian Address (if different)

Parent/Guardian Phone

Parent/Guardian Email

Treatment and Medical Conditions:

Treatment Needs (Select all that apply) * Required

Gynecological Care

Primary Care (PCP)

Medication Management

Therapy

Treatment Preferences * Required

In-Person Visits

Telehealth Appointments

Both In-Person & Telehealth

Reason for Visit

Have you been treated for your conditon in the past?

Yes

Prior Treatment

Insurance

I declare that the info I’ve provided is accurate & complete

How did you find us?

Message received. Thank you for joining our community! We will be in touch soon.

We are currently accepting new patients for early fall.

Become a Client - Signup

Contacts:

Hours:

office: 203.441.6676

e- fax: 833.428.1507

fax: 203.441.6176

e-mail: info@tmw-health.com

Monday - Friday: 9am-5pm
Therapy Hours - Vary
Saturday & Sunday - Closed

Confidential Inquiries:

Name

Phone

Address

Subject

Message

How did you find us?

Thanks for submitting! We are accepting new patients this year.

PLEASE READ

To receive the optimal healthcare that TMW can deliver, we highly recommend that clients COMPLETE ALL required documents.

The Patient Portal Intake process can be cumbersome, but completion will increase satisfaction, efficiency, and case management while minimizing errors.

REMINDER OF CANCELLATION POLICY

We’re always here for you and because our schedule fills up quickly, we kindly ask that you respect the following policy:

Late Cancellation: $85 fee if canceled with less than 24 hours’ notice
No-Show: $100 fee for missed appointments without notice
To help maintain a calm, comfortable space, we kindly ask that patients limit the number of accompanying guests when possible.

We understand that things come up, and we truly appreciate advance notice so we can offer that time to another TMW community member.

Thank you for your understanding.

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Kindly leave us a review, your input is valuable.

Kindly leave us a review... they really go a long way. : )

Se habla español.

The Modern Woman

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