Patient
Please review the below information and change any inaccuracies so that we have the most current information about you. You can add an emergency contact person by clicking “add a contact”. If you have a Health Care Card, and would like to access discounted services, email your current healthcare card to admin@theicebergfoundation.org.
* All questions and fields are mandatory (excluding timezone). Fill out all fields as best as you can to ensure a smooth intake process.
