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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.

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

Treatment and Medical Conditions:

Treatment Needs (Select all that apply)
Treatment Preferences
Have you been treated for your conditon in the past?

Thank you for your submission. A member of our staff will review your information and reach out to you within 24 hours.

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