New Patient Form
New Patient Form
Today's Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Physician Requested:
*
Dr. Maxam
Dr. Juarbe
Dr. Kennett
How many children in the family? (Full names please, i.e. middle initials, II, III, etc
*
Please Select
1
2
3
4
Name
*
First Name
Middle initial
Last Name
Suffix
.
*
Male
Female
Not Born Yet
DOB
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Due Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Name
*
First Name
Middle initial
Last Name
Suffix
.
*
Male
Female
Not Born Yet
DOB
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Due Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Name
*
First Name
Middle initial
Last Name
Suffix
.
*
Male
Female
Not Born Yet
DOB
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Due Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Name
*
First Name
Middle initial
Last Name
Suffix
.
*
Male
Female
Not Born Yet
DOB
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Due Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
If applying for newborn patient, what hospital was patient born at?
MyMichigan
Covenant
Other
Primary Contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
Secondary Contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian A
*
Parent/Guardian B
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
E-Mail Address
Guarantor/Name of Primary Insurer
*
DOB
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Name of Insurance
*
ID#
*
Group#
Please attach copy of insurance card (optional)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Secondary Insurance
Subscriber's Name
DOB
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
ID#
Group#
Do you currently vaccinate or plan to vaccinate?
*
Yes
No
If my child is accepted as a patient of the practice (Family Medicine Associates of Midland), I agree to follow recommended Preventive Pediatric Health Care guidelines to include well child exams, annual physical exams, and childhood immunizations.
Agree
Signature
How did you hear of Dr. Maxam, Dr. Juarbe, and/or Dr. Kennett?
Comments:
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