BG Internal Medicine & Pediatric Associates
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PROVIDERS
Sarah A. Mayfield, MD
Paul A. Kniery, MD
Kelly E. Kries, MD
Casey L. Miles, MD
Ashley R. Parrigin, APRN
Kyla M. Byard, APRN
Jenna E. Tarter, APRN
Ariel J. Mujakovic, APRN
Portal
Patient Portal
Patient Portal Request
patient info
ACO Annual Notice
billing
>
Financial Assistance
Insurances & Billing Department
Pay your Bill
Covid 19
>
COVID 19 Vaccine Information
HIPAA
Important Office Updates
Medical Grade Ear Piercing
Office Policies
>
Immunization Policy
No Show Policy
Sports/Camp Physicals
Televisits
forms
Registration/Well Child Forms
New Patient Information
Clinical Research Opportunities
Answers to After Hours Questions
Contact Us
Dosage Tables
Office Information
Online Appointments
Resources
Car Seat Regulations
Newborn Booklet
Parent Handouts
Related Links
Symptom Checkers
24 Hour Nurse Hotlines
Inclement Weather Plan
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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
[object Object]
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
Home
PROVIDERS
Sarah A. Mayfield, MD
Paul A. Kniery, MD
Kelly E. Kries, MD
Casey L. Miles, MD
Ashley R. Parrigin, APRN
Kyla M. Byard, APRN
Jenna E. Tarter, APRN
Ariel J. Mujakovic, APRN
Portal
Patient Portal
Patient Portal Request
patient info
ACO Annual Notice
billing
>
Financial Assistance
Insurances & Billing Department
Pay your Bill
Covid 19
>
COVID 19 Vaccine Information
HIPAA
Important Office Updates
Medical Grade Ear Piercing
Office Policies
>
Immunization Policy
No Show Policy
Sports/Camp Physicals
Televisits
forms
Registration/Well Child Forms
New Patient Information
Clinical Research Opportunities
Answers to After Hours Questions
Contact Us
Dosage Tables
Office Information
Online Appointments
Resources
Car Seat Regulations
Newborn Booklet
Parent Handouts
Related Links
Symptom Checkers
24 Hour Nurse Hotlines
Inclement Weather Plan
New Page