New Patient Enrollment Form

New Patient Enrollment

*All visits are through telehealth only*
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Sex*
Contact Number:*
E-mail*
example@example.com
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Marital Status*
In case of emergency
Emergency Contact:*

First NameLast Name
Relationship*
Contact Number*
Insurance
Primary Insurance
Insurance Name, if none type N/A*
Subscriber ID, if none type N/A*
Group Number, if none N/A*
Subscriber*

SelfSpousePartnerParentN/A
Subscriber Birthdate*

MonthDayYear
Date
Secondary Insurance
Insurance Name, if none type N/A*
Secondary Subscriber ID, if none type N/A*
Group Number, if none N/A*
Subscriber

SelfSpousePartnerParentN/A
Subscriber Birthdate

MonthDayYear
Date
Taking any medications, currently?*

YesNo
If yes, please list it here. Otherwise type N/A*
Allergies (If no, mark N/A)*
Pharmacy name and address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Appointment Type*

Acute CareChronic CareWeight LossPhysical (School, Work, DOT)Travel Health (Counseling and medication)Vaccines (COVID, Yellow Fever only)Mental Health (go to home page and select)Other
If other, list here
Upload a copy of your photo ID*
Privacy Policy

Terms and Conditions
Do you agree with the terms and Conditions*

I AGREEI DO NOT AGREE
Signature*

Clear
Please verify that you are human*
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New Patient Enrollment