New Patient Form
New Patient Form
Today's Date
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Physician Requested:
*
Dr. Maxam
Dr. Juarbe
How many children in the family? (Full names please, i.e. middle initials, II, III, etc
*
Please Select
1
2
3
4
Name
*
First Name
Middle initial
Last Name
Suffix
.
*
Male
Female
Not Born Yet
DOB
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Due Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Name
*
First Name
Middle initial
Last Name
Suffix
.
*
Male
Female
Not Born Yet
DOB
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Due Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Name
*
First Name
Middle initial
Last Name
Suffix
.
*
Male
Female
Not Born Yet
DOB
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Due Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Name
*
First Name
Middle initial
Last Name
Suffix
.
*
Male
Female
Not Born Yet
DOB
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Due Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
If applying for newborn patient, what hospital was patient born at?
MyMichigan
Covenant
Other
Primary Contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
Secondary Contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian A
*
Parent/Guardian B
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
E-Mail Address
Guarantor/Name of Primary Insurer
*
DOB
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Name of Insurance
*
ID#
*
Group#
Please attach copy of insurance card (optional)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Secondary Insurance
Subscriber's Name
DOB
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
ID#
Group#
Do you currently vaccinate or plan to vaccinate?
*
Yes
No
If my child is accepted as a patient of the practice (Family Medicine Associates of Midland), I agree to follow recommended Preventive Pediatric Health Care guidelines to include well child exams, annual physical exams, and childhood immunizations.
Agree
Signature
How did you hear of Dr. Maxam & Dr. Juarbe?
Comments:
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