Patient Form – BAC HEALTH SERVICES LLC

240 713 8080
bachealthservices@gmail.com

Home
About Us
Services
Insurance
Contact Us

Home
About Us
Services
Insurance
Contact Us

We offer compassionate, expert mental health care tailored just for you. From therapy and medication management to holistic wellness support, we’re all about empowering you on your journey to wellness.

Get In Touch

240 713 8080

Phone

bachealthservices@gmail.com

Email

14300 Cherry Lane Court, Suite 108, Laurel, MD 20707

Address

Patient Form

Home
Patient Form

First Name *

Last Name *

Date of Birth *

Sex * MaleFemale

Phone Number *

Email Address *

Do you take medication? *

Kindly provide a list of the medications. *

Do you have medication allergies? *

Kindly provide a list of the allergies. *

Full Address *

What is your Medical History? * Generalized Anxiety DisoderBipolarSchizophreniaSubstance Use DisorderDissociative Identity DisordersBorderline Personality DisorderDepressionADHDEating DisordersObsessive Compulsive DisordersASDPTSDBehavioral And EmotionalDisorders in ChildrenChest PainRespiratoryCardiac DiseaseCardiovascularHematologicalLymphaticNeurologicalPsychiatricGastrointestinalGenitourinaryWeight GainWeight LossMusculoskeletalOthers

Do you use or have history of tobacco? *

How often do you consume tobacco? *

Do you use or have history of using illegal drugs? *

Kindly provide a list of the illegal drugs. *

How often do you consume alcohol? *

Do you have a physician? *

Reason for visit? *

What date and time are you available for an appointment? *

Do you have insurance? *

What type of insurance? *

Which is your preferred pharmacy to send medication? *

SMS Consent YesNo

Message *

By checking this box, I consent to receive text messages related to Appointment Reminders / Follow-up Messages / Billing Inquiries from BAC Health Services, LLC. You can reply “STOP” at any time to opt-out. Message and data rates may apply. Message frequency may vary, text HELP for assistance. For more information, please visit our Privacy Policy and SMS Terms and Conditions.

First responder training

Basic Life Support (BLS), Cardiopulmonary Resuscitation (CPR), Automated External Defibrillator (AED) training, First Aid, and Advanced Cardiovascular Life Support (ACLS).

Treat the patients with a variety of mental health conditions: Depression, Anxiety, Bipolar, PTSD, Schizophrenia, SUD, BPD.

Services

Medication Management
Healthcare Training
BAC Staffing Agency
Talk Therapy
Individual Therapy

Alma
Psychology Today
Zocdoc

Quick links

Patient Form
Our Services
About Us
Insurance
Contact

Contact

bachealthservices@gmail.com

Email

14300 Cherry Lane Court, Suite 108, Laurel, MD 20707

Address

Copyright 2025 - All Rights Reserved By

Hyphen

Privacy Policy
SMS Terms