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)?*

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.
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.

Insurance Information
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

Current Symptoms & Preventive Health
Are you currently experiencing any symptoms you would like evaluated today?*

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
Are you currently up-to-date on all the vaccines?*

NoYesNot sure

Consent & Submission
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.
Please confirm: I confirm the information I provide in this application is true and complete.*

Yes, I confirm
Today's Date*

MonthDayYear
Date
Signature*

Clear
Should be Empty:

Patient Demographics