Guest Patient Visit Form

We are happy to hear that you would like to schedule a guest visit at one of our treatment centers.

In order to complete the process, please contact your current Counselor to advise them of your travel so that they can support you with the proper paperwork to guest medicate at one of our treatment centers. This is a requirement in order to guest dose at another treatment center.

If you have any questions for us regarding being a guest, please fill out this form and a member of our treatment team will get back to you as soon as possible. Please include an email and phone where we can reach you to answer your questions. Thank you.

First Name *

Last Name *

Email *

Phone *

Select the New Season Treatment Center you want to visit as a guest *

Select the New Season Treatment Center you are transferring from (if not listed, enter below)

Enter non-New Season Treatment Center transferring from

Beginning visit date

Ending visit date

Current treatment phone number *

Current treatment fax number

Message

Guest Patient Visit Form

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