Please enable JavaScript in your browser to complete this form.121. Patient DetailsName *FirstLastDate of BirthAgeGenderMale FemaleOtherMartial StatusSingle MarriedDivorcedWidowedReligionNationalityOccupationContact InformationAddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone *Alternate Phone No.Emergency Contact/ Guardian DetailsFull Name *Retlation to PatientPhone no.Email *AddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeMedical HistoryPrimary Past Psychiatric/Medical HistoryDepression AnxietyPsychosisBipolarEpilepsyDiabetesHypertensionAddictionOthersAllergies (if any)Substance Use History (if applicable)AlcoholCannabisHeroinBrown SugarInhalantsOthersNextUpdating preview…Indemnity Clause As the legal guardian/responsible person, I understand and accept that: 1. I shall be fully liable and financially responsible for any damage caused by the patient to the property, infrastructure, equipment, or staff of The Human Mind, whether intentionally or unintentionally. 2. I hereby agree to indemnify and hold harmless The Human Mind, its founders, doctors, therapists, staff, and management, from any legal, medical, or financial claims arising out of the patient’s actions, behaviour, or mental/physical condition during their stay or after discharge. 3. I understand that failure to follow treatment protocols, absconding from the facility, or any form of aggression or disruption caused by the patient will be dealt with seriousness, and all costs/damages will be borne by me, the undersigned. PreviousSubmit