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Account Information

DOB is required because many pharmacies and insurances require it. It also assists with patient lookup.

SSN is required for most insurances

Emergency Contact or POA
or Parent / Guardian Information

(Optional)

Preferred Pharmacy

If your pharmacy is not listed, select other, and email us with your pharmacy so we may add it to our list.

Insurance

If you have insurance, you will be able to add it on your account page after you sign up.

Review our pricing page to see if we are credentialed with your insurance provider.

Credit/Debit Card


Payments to New Brain Frontier are processed through a 3rd party payment processor called Stripe that handles millions of small business transactions per day. We do not hold onto your credit card number; we store a customer id number, which only works between our clinic and you, similar to a handshake.

While New Brain Frontier has started to filing insurance claims on behalf of its patients with insurances it is credentialed with (please review pricing for more information), we still keep a credit card on file for several reasons. 1) No show or late fee. If you do not show up we charge a late or no show fee of $75. 2) Deductibles that your primary or secondary insurance does not cover. 3) If you do not have insurance, we charge the card on file. 4) If we are not credentialed with your insurance provider, we also charge the card on file after the appointment. However we provide you with all the claim information for you to file your own claim and collect with your own insurance after the appointment is complete.


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Patient Consent Form
HIPAA Form
Notice of Privacy Practices Form
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