Primary Care

1

Which state do you live in?* This field is required.

Kansas

Oklahoma

Texas

2

I am looking for a Primary Care Provider that offers

In-Person Appointments

Telehealth/Virtual Appointments

3

I am looking for Primary Care Provider that offers...* This field is required.

In-Person Appointments

Telehealth/Virtual Appointments

4

Which location would you like to be seen at for a Primary Care appointment?

Copperas Cove (TX)

Haysville (KS)

Jenks (OK)

Other

5

Great news! We're adding primary care services to more locations soon. Which city are you looking for primary care services in?

6

Would you like us to contact you if we start offering in-person primary care appointments in your area?

Yes

No

I would like to try a virtual (telehealth) appointment

7

Patient Name* This field is required.

First Name

Last Name

8

Patient Date of Birth* This field is required.Virtual appointments are for ages 12 and above.

Date

9

Your Name (if different from patient)

First Name

Last Name

10

Relationship to Patient

11

Phone Number* This field is required.

Please enter a valid phone number.

12

Email* This field is required.

example@example.com

13

Do you have health insurance?* This field is required.

YESNO

14

Discounted Self Pay Rates

Our office visits start at $125 with any additional testing or procedures also discounted to help keep your cost low.

Payment is due at, or before, the time of service. Cash, check, credit, and debit cards are all accepted.

15

Please take a photo of your insurance card:

16

What time of day would you prefer to have an appointment?

Morning

Noon

Afternoon

Evenings (5pm or later)

17

How would you prefer we contact you?

Phone

Text

Email