New Patient Appointment Request

New Patient Appointment Request

Complete this form to request a new patient appointment at The Yakima Clinic. A team member will contact you to confirm your visit.
Patient Information
Name

First NameLast Name
Preferred name (optional)
Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Preferred Method of Contact
Reason for Visit
Brief Reason for Visit / Establishing Care
Insurance Information
Insurance Company
Member ID
Group Number
Subscriber Name
Subscriber Date of Birth

MonthDayYear
Date
Upload Front of Insurance Card

Cancelof
Upload Back of Insurance Card

Cancelof
Acknowledgment and Consent
I understand this form is an appointment request only and is not a confirmed appointment. A member of the clinic team will contact me to schedule and confirm my appointment.
I consent to be contacted by phone, voicemail, text, and email regarding scheduling.
Should be Empty: