Before We Begin

This is part 1 of 2. After completing this form, you will receive a welcome email to complete your medical history and more prior to your appointment.

Note: We recommend completing this form on your computer. If you have issues, please try the following:

• Clear your browser history/cookies.
• Check for browser updates
• Try viewing the website in private/incognito mode.

If you are having trouble with the form or have questions, please contact us at welcome@carencia.com.

Providing Your Photo

Your photos are for safety and for your provider to accurately identify you for treatment purposes. Your photo is Protected Health Information (PHI) and will be securely stored in your medical record. Your photo is not shared or used outside of Carencia and for treatment purposes only. You can always easily update your photo later if you prefer.

Contact Information

Referral Information

Financial Responsibilities

AN HONEST APPROACH TO BILLING & FEES

Finances can be a subject that medical practices avoid discussing. At Carencia, our financial transparency is a point of pride. We know that the intersection of financial realities and empathy is complicated, logistically and emotionally, so we’ve chosen to address this dilemma directly.

How Carencia Uses Your Financial Information:

Your card will not be charged today. Carencia securely stores your encrypted payment information, and we will only charge your card on file in the event of a late cancellation or missed appointment. For more information regarding our policies, please refer to our financial agreement. If you do not see a charge on your card for a missed appointment or late cancellation, please expect a request for payment at your next visit.

Carencia's Stance on Missed & Canceled Appointments:

We understand that late cancels and missed appointments can occur for many reasons, but the way in which they impact us goes beyond economics. It also means we’ve missed an opportunity to assist another patient during that same time. It’s our sincere hope that you understand our perspective.