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Flu Shot Clinic Consent Form
COVID 19 Vaccine Information
Home
Covid 19
Pay your bill
Patient Portal
Online Appointments
Newborn Booklet
Physicians
New Patient Request
New Patient Information
Televisits
Office Information
Forms
Office Policies
Sports/Camp Physicals
Clinical Research Opportunities
HIPAA
Hospital Affiliations
Answers to After Hours Questions
Related Links
Tylenol and Ibuprofren Dosing Instruction
Symptom Checkers
24 Hour Nurse Hotlines
Car Seat Regulations
Resources
Patient Portal Request
Contact Us
Follow us on Facebook
Flu Shot Clinic Consent Form
COVID 19 Vaccine Information
Please use this form only if you are a
new patient
.
Please note that it takes up to
2 weeks
for a response to new patient requests.
Please call 911 if you are experiencing a medical emergency.
New Adult Patient Request Form
*
Indicates required field
Patient Name
*
First
Last
[object Object]
Gender
*
Male
Female
Date of birth
*
Daytime Phone
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Email
*
Reason for Appointment/Current Health Concerns:
*
CURRENT INSURANCE:
*
Anthem BCBS (Commercial)
Aetna (Commercial)
Humana (Commercial)
Med Center Health Plan
Wellcare of KY (Medicare)
Cigna
Medicare
United Healthcare
Tricare
UMR
Meritain Health
Other
Chronic Health Conditions, i.e. Diabetes, Hypertension, COPD or other:
*
Whom may we thank for your referral?
*
Who is your current primary care provider?
*
REASON FOR TRANSFER FROM CURRENT PCP (INSURANCE NETWORK ISSUE, ETC.)
*
Do you have any family members which are current patients of our practice? If so, which physician do they currently see?
*
Have you previously been seen by our practice? If so, by whom?
*
Is there a specific physician you would like to request to see?
*
Submit
Home
Covid 19
Pay your bill
Patient Portal
Online Appointments
Newborn Booklet
Physicians
New Patient Request
New Patient Information
Televisits
Office Information
Forms
Office Policies
Sports/Camp Physicals
Clinical Research Opportunities
HIPAA
Hospital Affiliations
Answers to After Hours Questions
Related Links
Tylenol and Ibuprofren Dosing Instruction
Symptom Checkers
24 Hour Nurse Hotlines
Car Seat Regulations
Resources
Patient Portal Request
Contact Us
Follow us on Facebook
Flu Shot Clinic Consent Form
COVID 19 Vaccine Information