Establish Primary Care with Olivia Burrell – New Patient Interest Form
Share your contact details and visit preferences so we can schedule your first in-person or telemedicine appointment.
Contact Information
Full name
*
First Name
Last Name
Date of birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email address
*
example@example.com
Preferred contact method
Please Select
Phone call
Text
Email
Best time to reach you
Please Select
Morning
Afternoon
Evening
Any time
City, state, and ZIP code
*
Who Is This For?
Who is this form for?
*
Please Select
Myself
My spouse or partner
My child
Another family member
Submitter’s name (if this form is not for yourself)
First Name
Last Name
Your relationship to the patient (if this form is not for yourself)
Please Select
Spouse or partner
Parent or guardian
Child
Sibling
Other family member
Other
How many people are interested in establishing care?
*
Please Select
1
2
3
4+
Type of Care
Which care option are you interested in?
*
Concierge membership
Insurance-based care
Not sure — I'd like to learn more
Concierge membership type of interest
Please Select
Individual
Couple
Family
Would you like us to send membership pricing and details?
Yes
No
Insurance type
Please Select
Commercial/private
Medicare
Medicare Advantage
Medicaid
Tricare
Other
Insurance company name
Visit Preferences
Preferred Visit Format
In-person
Telemedicine
Either is fine
How Soon Do You Need an Appointment?
Within 1 week
Within 2 weeks
Within a month
I'm flexible
Preferred Days
Monday
Tuesday
Wednesday
Thursday
Friday
Preferred Time of Day
Morning
Midday
Afternoon
Current Primary Care Provider Status
Yes, transferring care
No, I don't have one
I had one but it's been over a year
General Reason for First Visit
Establish care
Annual physical or wellness visit
Medication refills or management
Ongoing care for an existing condition
Other
Final Details
How did you hear about our practice?
Please Select
Google search
Social media
Friend or family referral
Another provider referral
Other
Anything else you'd like us to know?
Contact consent
*
I agree to be contacted by phone, text, or email regarding scheduling and services.
Acknowledgment
*
I understand this form is not for urgent or emergency medical needs, and submitting it does not establish a provider-patient relationship.
Submit
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