New Patients

Welcome to the Team!

Thank you for considering our practice! Feel free to stop by the office to meet the doctors and staff. If you are already convinced that we are right for you and want to spend less time in the waiting room (who wouldn't), then please fill out the New Patient Form below and click submit.

Accepted Insurance:

All major insurance providers are accepted with exception to the following: Amerigroup, Wellcare, and AetnaBetter Health.

Below you will find a copy of our office policies, effective January 2019.

Please take a moment to read them over. Printing the form to bring to your first appointment is optional, but you will be asked to sign a copy at that visit.

Office Policy

New Patient Form

Note: Please complete this form in one sitting. If you click the back button before clicking submit, all parts filled out will be deleted

Date

YYYY

Allergies

Patient Name

First Name

Last Name

Patient Birthdate

YYYY

Patient Address

Patient Sex

Patient Phone #

guardian phone number is okay

(###)

###

####

Patient Social Security #

Patient's Insurance Company

(1)

if none, write "none"

(2)

not required

Subscriber

(1)

(2)

Responsible Party

Address

(if different than patient's)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Birth Date

YYYY

Sex

Social Security #

Phone Number

(###)

###

####

Marital Status

Do you have legal custody of the child?

Yes

Who does the child live with?

Is child adopted or a foster child?

Yes

Mother

Name

First Name

Last Name

Address

if different from patient's

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Employer

if unemployed, write "unemployed"

Social Security Number

Birthdate

YYYY

Home Phone

(###)

###

####

Work/Cell Phone

(###)

###

####

Father

Name

First Name

Last Name

Address

if different from patient's

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Employer

in unemployed, write "unemployed"

Social Security Number

Birthdate

YYYY

Home Phone

(###)

###

####

Work/Cell Phone

(###)

###

####

Child's Previous Physician

If we are your first, write "none"

Emergency Contact

Emergency Contact Phone Number

(###)

###

####

In the event of a medical need, I authorize the following people to bring my child in for medical care when I cannot:

Patient Release

I certify the information that I have provided is correct. I authorize the release of medical information necessary to process insurance claims to insurance companies or their agencies (including Medicare), for the purpose of filing and payment of medical claims. I authorize payment of medical benefits to the provider. I ACKNOWLEDGE THAT INTEREST OR A FEE, AT THE PROVIDER'S CURRENT RATE, MAY BE CHARGED on all balances owed to the provider that are past due.

Yes

Please Verify all information is correct before clicking submit

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