Primary Care Patient Application

Primary Care Patient Application

Welcome to OneSpotMD! We’re glad you’re considering us for your primary care. To give you the best experience, we ask a few questions about your health and insurance. This helps us review your history to make sure we’re the right fit for your healthcare needs. It also allows us to confirm that we’re in network with your insurance so you won’t face unexpected medical bills later.
Patient Demographics
Legal Name

First NameLast Name
Date of Birth (DOB)

MonthDayYear
Date
Age
Today

MonthDayYear
Date
What sex were you assigned at birth (on your original birth certificate)?
Current Home Address

Street Address

Street Address Line 2

CityState

Zip Code
Email
Please enter a valid email where we can send the lab results in the future if needed.
Cell Phone
Please enter a valid phone number that has ability to receive text messages.Format: (000) 000-0000.
To make sure we provide the best care, which language do you prefer for your medical visits?
Please specify the language
Emergency Contact

First NameLast Name
Emergency Contact Relationship
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
- Primary Insurance Provider
- If Other, please specify
- Please upload a copy of your insurance card (front and back).
  
  You may upload a photo of your insurance card (front and back). For best results, please upload as JPG, PNG, or PDF.
  Cancelof
- Do you have any current or past medical conditions? (Select all that apply)
- Other (please specify)
  Please list all the other conditions
- Are you currently experiencing any symptoms you would like evaluated today?
- You’re always welcome to come in for a same-day sick visit if you have any acute concerns.
  
  Preventive checkups are best done when you’re healthy, so your labs and screenings give clear results.
  
  This does not stop you from becoming a primary care patient. If you have an ongoing issue, like back pain, we can still see you for that before scheduling your yearly physical
- Are you currently up-to-date on all the vaccines?
- Have you had any surgeries in the past?
- List all your surgeries
- Are you currently on any prescription medications for any chronic conditions?
- List all your medications you currently take
- Do you need a refill on any medications?
- Please list the medication(s) you need refilled.
- Do you have a family history of any of the following?
- Please specify family history
- Consent to Review
  
  By submitting this application, I understand and agree that:
  
  OneSpotMD will review my medical history, medications, and the information I provide before deciding if I can be accepted as a primary care patient.
  Preventive annual physicals are scheduled only at the Steele Creek office. Sick visits, injuries, or follow-ups may be scheduled at either the Plaza Midwood or Steele Creek location.
  
  Submitting this form does not guarantee acceptance as a primary care patient. If I am not accepted, I am still welcome to use OneSpotMD for urgent care and walk-in visits.
  
  I consent to receive appointment-related communications from OneSpotMD by text message and email, including application updates, scheduling confirmations, intake forms, visit reminders, and pre-visit instructions. Message and data rates may apply.
  
  I may opt out of text messages at any time by replying STOP and unsubscribe from emails at any time.
- Text Message Consent (Optional)
  
  I consent to receive non-marketing SMS text messages from OneSpotMD Primary and Urgent Care PLLC related to appointment reminders, visit confirmations, check-in instructions, follow-up care messages, lab notifications, and billing communications. Message frequency may vary. Message and data rates may apply. Reply STOP to opt out at any time. Reply HELP for assistance. SMS consent is not a condition of receiving medical services.
- Promotional Messages (Optional)
- Please confirm: I confirm the information I provide in this application is true and complete.
- Today's Date
  
  MonthDayYear
  Date
- Signature
- SMS Disclosure
  
  OneSpotMD Primary and Urgent Care PLLC uses SMS messaging to communicate with patients who voluntarily provide their mobile number and opt in. Messages may include appointment reminders, visit confirmations, check-in instructions, follow-up care messages, lab result notifications, and billing communications. Message frequency varies based on patient interaction. Message and data rates may apply. Reply STOP to opt out at any time. Reply HELP for assistance. SMS consent is not a condition of receiving medical services.
  
  Contact: info@onespotmd.com
  
  Link to our privacy policy
  
  Link to our terms of services
- Should be Empty:

Primary Care Patient Application

Patient Demographics