New Patient Screening Form

New Patient Screening Form
Thank you for your interest in establishing primary care with our practice. Please complete the form in full. As part of our review process, we verify your insurance coverage, which requires your social security number. Additionally, be prepared to provide your contact information, specific insurance details, and basic health history. Applications cannot be processed without this information.

Prior to completing this form, we request your acknowledgement that our physicians and nurse practitioners are committed to a proactive, prevention-focused approach to health, emphasizing cancer screenings, recommended vaccinations, annual wellness visits, and consistent follow-up visits for patients with chronic medical conditions. We believe this structured, engaged partnership leads to the best long-term health outcomes. If this is not the type of medical care you are seeking, we kindly ask you consider another local provider who may be a better fit for your needs. We look forward to partnering with you!
Yes
This form is HIPAA compliant and secure. We need your social security number for insurance verification purposes. You can choose to enter it here, or our office staff will contact you to collect it after submission.
For Insurance Verification*
Number
Email*
example@example.com
Which doctor or nurse practitioner do you request to see?*
Name*

First NameMiddle NameLast Name
Preferred Name
Best Contact Number*
Date of Birth*

MonthDayYear
Date
Age*
MaleFemale
Preferred Pronouns (optional)
Address (Please include the street, city, and zip code)*
Street, City, Zip Code
How did you hear about us?*
NoYes
What type of insurance do you have?*
Please list as it appears on your insurance card
Insurance member ID number*
As it appears on the front of your insurance card
NoYes
NoYes
Who is your current or most recent physician or nurse practitioner?*
What was the date of your last full wellness exam or physical?
If you do not know the exact date, please give you best approximation.
What was the date of your last full wellness exam or physical?*

MonthDayYear
Date
NoYes
Please list all current PRESCRIPTION medications. We cannot process your form without this information.*
In order for us to allow adequate time for your initial new patient visit, please check all of the following conditions for which you have been previously treated for or are currently being treated for.*

ADHD/ADDAnemiaAnxiety or depressionArthritisAutoimmune disorder including Lupus, Rheumatoid Arthritis, Ulcerative colitis, PsoriasisBack PainCancerChronic PainDementiaDiabetesDizzinessFrequent fallsGoutHeadachesHeart diseaseHeart failureHigh blood pressureHigh cholesterolIrregular heart beatKidney diseaseLiver DiseaseLung disease including asthma, copd, fibrosis, frequent bronchitisNeurological conditions including Parkinsons, Multiple Sclerosis, paralysisSeasonal allergiesSeizuresSinus troubleSleep ApneaStomach/intestinal problemsStrokeThyroid diseaseWeight loss or gainNo concerns at this timeOther
What are your health goals for the next year? Please list 2 or 3 *
Is there anything else you would like us to know that will help us care for you?*
Thank you!

The office will contact you upon review to collect your social security number for insurance verification purposes. Your application will not be processed until we have received this information.
Your application will be processed, and we will reach out to you with a determination as soon as possible.
Should be Empty:

New Patient Screening Form

Thank you!