New Patient Information
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Patient Portal Request
Please use this form only if you are a
Please note that it takes up to
for a response to new patient requests.
Please call 911 if you are experiencing a medical emergency.
New Pediatric Patient Request Form
Indicates required field
Date of birth
Casey Miles, MD
Ashley Parrigin, APRN
Emily Cope, APRN
What is the name of your current insurance plan?
Is the request for a new baby? If so, is the child already born or what is the expected due date?
Is the child fully vaccinated or are you planning to vaccinate per the CDC schedule?
Who is current primary care provider?
Whom may we thank for referring you?
Bowling Green Internal Medicine & Pediatric Associates
1701 Ashley Circle Suite 200
Bowling Green, KY 42104
Phone: (270) 846-4800 Fax: (270) 846-4828