New Patient Application

Name

DOB

Phone #

Insurance

Who is your current or last Primary Care Provider:

Do Not Have One

Reason for Leaving:

Medical History/Current Problem(s):

OR None

Current Medications:

OR None

Requested Provider:

Jared Richardson, MDNancy Smith, FNPJessica Jones, PAAli Lawing, FNP

How did you hear about Upstate Medical Associates, P.A?

NewspaperOnline (Social Media, Google, etc)Referred byOther

Please provide the referrer's name:

*** READ CAREFULLY BEFORE SIGNING ***

It is our office policy NOT to accept any new patients who are taking controlled medications on a long term basis. These include opioid pain medications such as hydrocodone, tramadol, oxycodone or any other opioids and benzodiazepines like diazepam (Valium) and lorazepam (Ativan). These medications are just a few examples since there are many others in these categories. If the use of a controlled medication becomes appropriate for you while you are our patient, it will be used on a short-term basis as needed.

Please provide an accurate medication list with your application. If you are accepted and your medical records indicate you are currently and chronically taking these medications, your appointment will be cancelled and you will be discharged from the practice. If you have any questions about these medications, please contact our office.

I agree that all the above information, in particular the medications and current problems, is accurate, true, and current as of the date below. I understand that if I have not provided accurate information or have failed to include important medical information on this form, I will be immediately discharged from the practice.

Signature

Date

15575 Wells Hwy
Seneca, SC 29678

Ph: (864) 886-2000
Fax: (864) 888-3618