For each form, Please Click or Copy and paste the related URL to your Browser, then fill out the form.

Enquiry Submission form(Contact Form):


New Patient Registration Form:


Success Health System Release-Obtain Medical Records


Provider Referral Form:


Consent to Treatment Form:


Succes Health System Medical Records Request Service Fee Agreement:


Acknowledgement of Privacy Form:


Direct Care Patient Agreement Form:


Insurance Contract Form:


Intake Form ADULT:




Follow UP Form( All Ages):


Suboxone Treatment Contract Form:


Self-Pay Contract Form:


Medication Refill Request Form:


Success Confidentiality and non-disclosure agreement: