New Patient Application

New Patient Application

Lakeside Clinic, LLC
Legal Name (Please verify correct spelling.)*

First NameLast Name
Phone Number*
Secondary Phone Number
Please enter a valid phone number.
Date of Birth (Please verify date of birth is correct.)*

MonthDayYear
Insurance (PLEASE NOTE- We are NOT currently accepting the following insurance plans: Medicaid, United Healthcare, Tricare Prime, Cigna HMO, Ambetter, or First Health.)*
Type of Insurance Plan (i.e. HMO, PPO, ALONEX, DSNAP, etc.)
If available, please upload image of your insurance card(s). ***This section is not required, but may help us determine your coverage.

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Referred by
Previous MD*
Location of Previous MD*
Problem List*
Past/Present Diagnoses or Concerns
Medication List*
To expedite the application process, we recommend selecting multiple doctors or the 'First Available' option. If you have any questions, please contact our office. Please note that some applications may require more than 4-5 days for processing.
Requested Doctor*

Dr. Joshua BellDr. John BoggessDr. Wade Edwards (with Carleigh Winslett, CRNP)Dr. Morgan Jackson (with Amanda Rowe, CRNP)Dr. Joel Milligan (with Dayleigh Wisener, CRNP)Dr. Alex Nixon (with Stephanie Beaver, CRNP)Dr. Jeffrey Saylor (with Stephanie Beaver, CRNP)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!
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