Email ECHS directly: info@extracarehealth.com
or complete the form below:


First Name: Last Name :

Address City: State:

Date of Birth: Sex:

Cell/Alternate Phone:

Home Phone:


Alcohol/Drug Use

Primary Substance :

Secondary Substance :

Third Substance :


Health Insurance Information

Patient Name : ID# :

Group # :

Phone Number(s) on Insurance Card :

Insurance Carrier :


Your Contact Information

Email:

Best Time to Contact You:


Comments/Additional Information:
Type comments here.