Yelm Prairie New Patient Appointment

1

Name* This field is required.

First Name

Last Name

2

Date of birth* This field is required.

Date

3

Email

example@example.com

4

Phone* This field is required.

Please enter a valid phone number.

5

Can we text you at this number?

YESNO

6

What is your preferred method of contact?

Email

Text

Phone

7

Do you have insurance?* This field is required.

YESNO

8

Upload photos of the front and back of your insurance cardAttach a photo of the front and back of your insurance card. If you don't have your insurance card, click NEXT and you can text or email it to us later

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

9

Primary insured name

Name of the person the insurance is under

10

Primary insured date of birth

Date

11

Do you have any other insurance?* This field is required.

YESNO

12

Upload photos of the front and back of your insurance cardAttach a photo of the front and back of your insurance card. If you don't have your insurance card, click NEXT and you can text or email it to us later

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

13

Do you have Medicare?* This field is required.

YESNO

14

Upload photos of the front and back of your Medicare cardAttach a photo of the front and back of your Medicare card. If you don't have your Medicare card, click NEXT and you can text or email it to us later

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

15

Is this visit for a car accident or an on-the-job injury?

YESNO

16

Which one?

Car accident

On-the-job injury