New Patient Request Form

New Patient Request Form
Patient approval process takes from 3-5 business days from the form is submitted.

All spaces must be completed before submitting.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Male or Female*
Race*
Primary Language*
Do you smoke?*

YesNo
Do you smoke?*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone*
Cell Phone*
Work Phone*
Email*
example@example.com
Insurance Provider*
Previous MD*
Social Security Number*
Guarantor Name*
if applicable
Relationship to child*
if applicable
Guarantor Date of Birth*

MonthDayYear
if applicable
Date Submitted*

MonthDayYear
Date
Appointment Date*

MonthDayYear
Date
Concern at this time*
Medical Conditions and Previous Surgeries*
Current Medications - please list in paragraph form with a coma separating each one.*
SAMA Healthcare is a primary care clinic and will only be accepting patients who intend to use our office as their primary health care provider. We will not accept new patients to be seen only for acute Issues. All patients who submit new patient forms may be searched on the prescription monitoring database before being accepted. This database shows all controlled medications which have been prescribed to the patient recently.
Which provider would you like to see?*
Should be Empty: