New Adult JET

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 watch your email for a response.
Please call 911 if you are experiencing a medical emergency.

New Adult Patient Request Form -
Jenna Tarter, APRN

* Indicates required field

Patient Name *

First

Last

Date of birth *

Gender *

Male Female

Daytime Phone *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Email *

Current Insurance: (Specify whether Medicare , Medicaid or Private Ins) *

Reason for Appointment/Current Health Concerns: *

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? *

Submit

New Adult Patient Request Form -
Jenna Tarter, APRN

OFFICE HOURS

Monday-Friday 8 am to 5 pm
Saturday 8 am to noon
Sunday closed

CALL US!
270-846-4800
Fax: 270-846-4828

FOLLOW US ON SOCIAL

PAY ONLINE

PATIENT PORTAL

New Adult Patient Request Form - Jenna Tarter, APRN

OFFICE HOURSMonday-Friday 8 am to 5 pmSaturday 8 am to noonSunday closed​

CALL US!270-846-4800​Fax: 270-846-4828

FOLLOW US ON SOCIAL

PAY ONLINE

PATIENT PORTAL

New Adult Patient Request Form -
Jenna Tarter, APRN

OFFICE HOURS

Monday-Friday 8 am to 5 pm
Saturday 8 am to noon
Sunday closed

CALL US!
270-846-4800
Fax: 270-846-4828