New Patient Application
Name
Home Phone
Mobile Phone
Email Address
Address
Date of Birth
Age
Employer
Employer Address
Insurance
Please enter your Insurance Provider Name, ID#, Group#, Customer Service Phone# & Address. If you have a secondary insurance please list the same for your secondary insurance & specify which insurance is primary & which is secondary.
5
Provider Request
Jay C. Proctor III MD
Bud Church PA
Jae Doyle NP-C
Aaran Gassiott, FNP-C
Amber N. Fling, FNP-C
William Kujawski RN, MSN, FMP, BC
Tracy Foster, FNP-C
Would you see our Physician's Assistant or Nurse Practitioner?
Yes
No
Current
Please write name of your current doctor & reason for changing. Please also list names & types of specialists you see here.
Reason for Visit
Please write what you need treatment for & if you are presently having chest pain or shortness of breath.
Do you take any of these medications?
Xanax-Alprazolam
Soma-Carisoprodol
Vicodin-Hydrocodone
Ativan-Lorazepam
List all additional medications you are taking or have taken recently:
7
History
Please check if you have history of:
Anxiety
Diabetes
Cancer
High BP
Heart Disease
Depression
Chronic Pain
Have you previously been treated for alcohol or drug addiction at any time?
Yes
No
List any allergies or medical conditions:
Emergency Contact
Emergency Contact Phone
Submit
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