New Patient Form

Patient's Legal Name *
Patient's Legal Name
Mailing Address *
Mailing Address
Phone *
Phone
Date of Birth *
Date of Birth
Name / Dose / How Often do you take?
If retired, please put retired/date of retirement. If student, please put name of school/part time or full time.
Employer Phone Number
Employer Phone Number
Spouse Name
Spouse Name
Spouse Date of Birth
Spouse Date of Birth
Spouse Phone Number
Spouse Phone Number
If retired, please put retired/date of retirement.
Spouse Employer Phone Number
Spouse Employer Phone Number
Responsible Party
If other than patient, please fill in below
Address 1
Address 1
Phone 4
Phone 4
Emergency Contact Information
Name of Friend or Relative
Name of Friend or Relative
Address 2
Address 2
Phone 5
Phone 5

Please note that we now require a copy of your Medicare, Medicaid and/or Insurance Card to verify the mailing address, phone number, and the spelling of your name as shown o each individual card. We cannot file insurance claims for you without the birthdate and social security number of the policy holder.

We are also requiring a copy of your driver’s license or other picture ID that includes your signature. This is to be able to verify your identity in the event of requests for release of Private Health Care information.

We appreciate your help and understanding of these requests.