Online New Patient Contact Form

1
Contact Name:* This field is required.
First Name
Last Name(s)
2
Best Contact Number:* This field is required.
Please enter a valid phone number.
3
Medical Insurance Provider:* This field is required.
Aetna
Blue Cross Blue Shield
Cigna
Humana
Medicaid
Oscar Health
Prime Health
Superior
TRICARE
United Healthcare
Self-Pay / Private Pay
Other
4
What is the name of your health insurance provider?* This field is required.
5
Type of Insurance (typically stated on your insurance card)* This field is required.
HMO, or Health Maintenance Organization
PPO, or Preferred Provider Organization
EPO, or Exclusive Provider Organization
POS, or Point of Service Plan
Other or Unknown
6
Do you currently carry any form of Medicaid insurance coverage?* This field is required.
YESNO
7
What is your preferred method to be contacted by our staff?* This field is required.
Phone Call / Voicemail (please ensure voicemail is set up for number given)
Text Message (please ensure number given is able to receive SMS messages)
8
Email
example@example.com
9
How soon do you need a new patient appointment?* This field is required.New patient appointment availability varies by medical provider.
Within the week
Within 2 weeks
Within 3 months
Within 6 months
Within 12 months
10
Is there a specific provider(s) you wish to schedule your appointment with (if he/she has availability within the time frame needed)? Choose any that apply.* This field is required.New patient appointment availability varies by medical provider.
No preference and/or soonest appointment available
Ms. Elieth (Ellie) Jaramillo, PA-C (Certified Physician Assistant)
Ms. Ashley Charles, PA-C (Certified Physician Assistant)
Dr. Samuel Landero, MD (Board Certified in Family Medicine and Obesity Medicine)
11
What days of the week and times of days work best for your schedule? IMPORTANT: New patients must arrive 30 minutes prior to appointment to fill out paperwork and to verify insurance.* This field is required.Check all that apply
No preference, soonest appointment available
Mondays
Tuesdays
Wednesdays
Thursdays
Fridays
First appointment of the day (9am - arrive at 8:30am)
Mid-morning
First appointment after lunch (2pm - arrive at 1:30pm)
Mid-afternoon
Last new patient appointment of the day (3:30pm - arrive at 3pm)
12
If you selected to be contacted via phone call / voicemail or if we need to contact you to collect additional information, when are the best days and times to call you Monday through Friday, 8am - 5pm?* This field is required.
13
Terms and Conditions* This field is required.
14
How did you hear about us?* This field is required.
Should be Empty: