PACE BEHAVIORAL HEALTH & TMS CENTERS

Instructions: Please enter your information in the section below. When finished, click “Proceed to Registration” to create your username and password. You must upload your insurance card and photo id failure to do so can result in denial into practice. Fill out all information and paperwork in its entirety

First Name:*

Last Name:*

DOB:*

Sex:*

E-mail:*

Mobile #:*

Home Phone #:

Address:*

Zip Code:*

Patient Availability:

Days:

Sun Mon Tue Wed Thu Fri Sat

Referral Source:

Reason for Visit:*

Facility:

Get email instructions in:

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Once clicking "Proceed to Registration", you can complete your registration now or return to complete it later by clicking the link in the initial email you received.

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Once clicking "Proceed to Registration", you can complete your registration now or return to complete it later by clicking the link in the initial email you received.

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