New Patient Enrollment Form

New Patient Enrollment

Bruce O'Very MD, Robert Cohoon D.O. , Emily Fonua FNP & Sarah Horton FNP
How did you hear about Treehouse Pediatrics?*

GoogleSocial MediaFriendRelativeDoctor/OBGYNJump Zone BannerInsuranceOther
Which provider are you wanting to be your Primary Care Provider?
Which provider are you wanting to be your Primary Care Provider?*

Dr. Robert Cohoon D.O.Dr Bruce O'Very MDNo Preference :) - Anyone at Treehouse Pediatrics!I am an adult with children seen at Treehouse Already!I am a new adult with no relation!Other
Treehouse Clinic is accepting new patients!

Dr. O'Very has trained his extenders (Emily Fonua and Sarah Horton) to see new adult patients on his behalf for the first appointment usually, and every other appointment as is reasonable, as his schedule can be a bit booked out for adults!

Dr O'Very trusts them completely and hand chose them to work at our office! As part of his Medical Team he has trained them to follow our practices here at Treehouse to maintain the same level of care as Dr. O'Very has!

We also have a pediatrician Dr. Cohoon who is currently building up his new practice!

All of the providers consult with Dr. O'Very often in order to maintain consistency in the practice! :)
Patient's Name*

First NameLast Name
Date of Birth*

MonthDayYear
Sex*
Textable Number:*
E-mail*
example@example.com
Billing Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Any current concerns:
Taking any medications, currently?*

YesNo
If yes, please list it here*
Where are you transferring care from?*

UtahIdahoWyomingOther
What facility are you transferring care from?
We need this for records requesting.
What facility are you transferring care from?*
We need this for records requesting.
Do you have or have access to immunization records for your child(ren)?*

YesNoOther
Please upload pictures or screenshots of the records here!*

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Primary Contact:*

First NameLast Name
Relationship*
Date of Birth*

MonthDayYear
Date
Contact Number*
Marital Status
Secondary Contact:

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.
Date of Birth

MonthDayYear
Date
Insurance Provider*

Medicaid - UTSelf PaySelect HealthBlue Cross Blue ShieldAetnaUnited HealthcareCignaOther
Just because its not listed, doesn't mean we don't take it!

We take majority of insurances! Those listed above are just most popular :)
Insurance Provider - Other than listed above*
Member ID #
Group #
Upload A picture of their Insurance Card

Cancelof
Any more Patients that will be joining our practice?*
Please put the Name, Gender, AND Date of Birth of any other patients that will be joining our practice! Or n/a if not applicable :)
By signing your name electronically on this Patient Information Form, you are agreeing that your electronic signature is the legal equivalent of your manual signature on this Form.

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