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
New Patient Request
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
AESTHETICS
Bowling Green Aesthetics
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 Pediatric Patient Request Form -
Jenna Tarter, APRN
*
Indicates required field
Patient Name
*
First
Last
[object Object]
Date of birth or Expected Due Date
*
If this request is for a new baby, is your child currently/or recently discharged, from the NICU?
*
Yes
No
N/A
If currently in NICU, expected date of discharge
*
If recently discharged from NICU, discharge date
*
Daytime Phone
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Email
*
Gender
*
Male
Female
Is the request for a new baby? If so, is the child already born or what is the expected due date?
*
Current Insurance
*
Aetna
All Savers Insurance
Anthem BCBS
Cigna
Coresource
Humana
Med Ben
Med Center Health
Tricare
UMR
United Healthcare
Other
*** Please be aware that currently our panels with all Medicaid MCO's are closed. We are unable to accept any new Medicaid patients at the moment, unless siblings are already established with the practice. We are sorry for any inconvenience.
Who is current primary care provider?
*
Is the child fully vaccinated or are you planning to vaccinate per the CDC schedule?
*
PLEASE LIST MEDICAL HISTORY:
*
CURRENT MEDICATIONS:
*
Name of Parent or Guardian and relationship to patient
*
Are there any current family members that see any physicians within our practice? If so, which physician?
*
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
New Patient Request
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
AESTHETICS
Bowling Green Aesthetics