Call us at (443) 619-0083
or at (443) 922-7079

Patient Initial Contact Form

Only a physician at ARCA will read this information. All your information will be kept in the strictest privacy.

However, please understand that due to FDA and AMA regulations, you are not a patient of ARCA until we have formally accepted your application. We hope that we will be able to meet with you soon and help you on the road to getting a new shot at life!

Note: You must fill in all the fields ABOVE the red line in order for the form to send. The questions BELOW the red line are optional; they help us in pre-evaluation.

First Name:
Last Name:
Sex: Male  Female

How do you want to be contacted?Cell Phone
Home Phone

Do you currently work?YesNo
What is your occupation/profession?

Do you have insurance/medical assistance?YesNo
Name of your health insurance:

What substances are you currently using?
Do you use substances like Opana, Methadone, Fentanyl?YesNo

Are you on Suboxone?YesNo
How much are you taking daily?

Are you on benzodiazepines: Xanax, Valium, Ativan, Klonopin?YesNo
How many?

Have you been treated for substance dependence before?YesNo
Do you currently go to NA:YesNo
Do you currently go to AA:
Are you currently getting counseling?

Are you pregnant or plan to get pregnant in the near future?YesNo

Is water wet or dry?
Please answer the above question so that we can be sure you are a human being!