Tranquility Behavioral Health Patient Portal

Available Forms

2024 TREATMENT AND CONSENT FORMS 2024 NEW PT Patient Questionnaires Appointment Cancellation Request MEDICAL RECORDS/PAPERWORK REQUEST MEDICATION REFILL REQUEST NEW PATIENT REQUEST NURSE MESSAGE FORM WAITLIST/ REQUEST FOR SOONER APPOINTMENT

Appointment Cancellation Request

Tranquility BHC Appointment Cancellation Request

Patient First Name: *

Patient Last Name *

D.O.B. *

Date of Appointment *

Provider *

Reason for Cancellation *

Will you have enough medication to last you until your next appointment? *

Yes

Please be advised that medication refills require an appointment. If you are in need of a refill, it is highly recommended that you keep your appointment.

Will you need to reschedule your appointment? *

YES

Requested Reschedule Date *

Please input the ideal date or time frame in which you would like to reschedule your appointment. If you do not wish to reschedule, please input N/A

Initials *

Submission Date *

* Required field