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
MaleFemalePrefer not to answer
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
- DiabetesHigh blood pressure (Hypertension)High cholesterolHeart disease (history of heart attack, heart failure, arrhythmia)AsthmaCOPD (chronic lung disease)Thyroid problemsCancer (current or past)Anxiety, DepressionMental health conditionsStroke or TIAKidney diseaseLiver diseaseArthritis or chronic joint painAutoimmune disease (e.g. lupus, rheumatoid arthritis)Neurological conditions (e.g. seizures, multiple sclerosis)OtherNone
- Other (please specify)
  Please list all the other conditions
- NoYes
- 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
- NoYesNot sure
- NoYes (please list)
- List all your surgeries
- NoYes (please list)
- List all your medications you currently take
- NoYes (please list)
- Please list the medication(s) you need refilled.
- Heart DiseaseDiabetesGenetic DisorderCancerOther (Please specify)None
- 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.
- 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.
- I consent to receive occasional promotional or informational SMS messages from OneSpotMD Primary and Urgent Care PLLC, such as clinic updates, service announcements, or special offers. Message frequency may vary. Message and data rates may apply. Reply STOP to opt out at any time. Reply HELP for assistance.
- Yes, I confirm
- 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