Tranquility Behavioral Health Patient Portal

Tranquility BHC NURSE MESSAGE FORM

First & Last Name * D.O.B. * PROVIDER * Date of Request * Are you having an adverse medication reaction? Chief Complaint * Are you Suicidal * If answered yes, do you have a plan?

If answered yes, please go to the nearest Emergency Room or call the office directly AFTER submitting this form.

All nurse messages submitted before 4:30 P.M. will be reviewed by the end of the business day of which you originally submitted your request. However, please allow up to 3 business days for any medication requests and pharmacy changes. There is a $15 fee for all Pharmacy changes.

Phone Number * Email * Date of MOST RECENT Appointment * Upcoming Appointment Date