New Patient Application
Lakeside Clinic, LLC
Name
*
First Name
Last Name
Phone Number
*
Email
*
example@example.com
Date of Birth
*
/
Month
/
Day
Year
Insurance
*
Referred by
Previous MD
*
Location of Previous MD
*
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Problem List
*
Past/Present Diagnoses or Concerns
Medication List
*
Requested Doctor
*
Dr. Joshua Bell
Dr. John Boggess
Dr. Wade Edwards
Dr. Morgan Jackson
Dr. Joel Milligan
Dr. Alex Nixon
Dr. Jeffrey Saylor
First Available
Please do not submit multiple requests, as this may delay response time. If you would like to check on the status of an existing application, please call our front desk at (256) 582-5131. Thank you!
SUBMIT
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