Big Trees MD NEW Patient Application

Big Trees MD New Patient Application

Thank you for your interest in becoming a Member of Big Trees MD! Go ahead and complete this form and after its completed, you'll be able to schedule your Meet & Greet! If you have any questions, please CALL or TEXT us at (209) 653-2135.
Full Name:*
Nickname:
Physical Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address different from Physical Address?*

YesNo
Mailing Address: (if different from Physical Address)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth:*

MonthDayYear
Date
E mail: *
example@example.com
Cell Phone:
Format: (000) 000-0000.
Other Phone:
Format: (000) 000-0000.
Insurance Information
Do you have health insurance?*

YesNo
Please upload a picture of the FRONT of your insurance card(s). *

Cancelof
Please upload a picture of the BACK of your insurance card(s). *

Cancelof
Do you have drug or pharmacy benefit insurance?*

YesNo
Please upload a picture of the FRONT of your PHARMACY BENEFIT insurance card(s).

Cancelof
Please upload a picture of the BACK of your PHARMACY BENEFIT insurance card(s).

Cancelof
Is this a high-deductible plan (Yes or No)?*
Enter your RX Bin number from your pharmacy card here: IMPORTANT!
Medical Care History
Who was your last PRIMARY doctor or non-physician practitioner?*
At what clinic were they located? *
What is their phone number?
Format: (000) 000-0000.
When was your last physical?*
Have you ever been admitted to the hospital or an emergency room?*

YesNo
If so, when was the last time and what were you treated for?*
What medical concerns have you been diagnosed with in the past?*
Please list any SPECIALISTS or alternative providers you've seen for the above diagnoses. List where they are located, what medicines do they prescribe, and what do you see them for? i.e. Dr. Iwata in Angels Camp for Optometry, last visit 1/12/21.
Cancer Screening History
Have you had a mammogram before?*

YesNo
If yes, when was your last one and where was it done?*
Have you had a colonoscopy before?*

YesNo
If yes, when was your last one and where was it done?*
Surgical History
Have you had any surgeries?*

YesNo
Please provide details of those surgeries here.
Medications and Supplements
Please list any medicines and supplements you have taken within the last year.*
Allergies
Do you have allergies to food or medications?*

YesNo
Please describe what allergies and reactions you have.
Health Goals
What health goals would you like to achieve in the next three months?
What health goals would you like to achieve in the next six months?
What health goals would you like to achieve in the next year?
Before your first meeting, is there anything you would like to share?
Thank you for taking the time to be as detailed as possible.

This form helps us greatly in getting you established in the practice!

Now let's get your Meet & Greet scheduled!!!

~The Big Trees MD Team
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Big Trees MD New Patient Application

Insurance Information

Medical Care History

Cancer Screening History

Surgical History

Medications and Supplements

Allergies

Health Goals