Patient Intake Form

Thank you for choosing Myrtle Recovery Centers.  Please complete our patient Intake form below. After you submit, our intake specialist will be in contact with you to discuss further and answer any other questions you may have.

Name *

First

Last

Address Line 1

City

Zip Code

State *

Phone Number *

Please enter your main phone number, which we will most likely get you on.

Email *

Questions or Comments

Are you over 18 years of age? *

• Yes, I am over 18 years old.

Submit

Your Journey to a better you starts now.