New Patient Request

OFFICE STIPULATIONS FOR ALL NEW PATIENTS TO UNDERSTAND AND ACCEPT BEFORE THEY PROCEED:

We highly advise reading through our website to learn more about our providers and office prior to requesting a new patient appointment
Make sure we are in network with your insurance company
We do not perform any pain management or prescribe chronic pain medication
We do not prescribe Xanax or other addictive controlled substances
We do not treat or prescribe medications for ADD/ADHD
Ultimately our providers have the right to use their prescription privileges as they see fit in regards to types of medications or quantities
Patients receiving treatment from mental/behavioral health specialists must continue to see those specialists/prescribers as we are not a replacement for those services
All patients are expected to be compliant with their health conditions and prescribed medications
The initial appointment will be to establish you as a patient of this office, and address any immediate concerns you may have. The initial appointment is not a physical
All financial responsibilities to include copays, coinsurance and deductibles will be collected at time of service
All children must be vaccinated on schedule, we do not delay immunizations
New patient appointments are scheduled Tuesday-Friday, between 9am and 2pm
All adults must submit their own request for a new patient appointment, we do not allow other adults to request appointments on behalf of other adults
You must not provide any Personal Health Information through email or other electronic format

I have read and accepted the above guidelines.*

ABOUT THE INITIAL SCHEDULING:

Individuals who have formerly been patients of our practice will not be allowed to return and our ineligible to use this requesting service
New patient appointments typically book about 3-4 weeks away. Until you have had this new patient appointment we will not treat or meet any health care needs you may have nor can we accept your health records
Upon receiving your new patient request, we will typically answer your request through email and provide a suggested date/time for your initial appointment
If you are unable to accept the appointment date/time we have set, you must CALL the office (not email) to reschedule as long as we are provided at least 24 hours notice prior to your appointment
If you fail to provide notice, at least the day before your appointment, to cancel or reschedule or you simply do not show for your first appointment we will not set any other appointments for you in the future
If you arrive more than 15 minutes late for your first appointment, we will cancel this appointment and will not reschedule
When possible, new patients will see our one of our Physician Extenders for their initial appointment
All of our providers “share” patients, and unless specifically assigned to one physician for insurance purposes, patients may see different providers from time to time depending on availability
If a patient is required to assign a provider by their insurance company, they must do so prior to their visit

I understand the appointment may be cancelled by the office or patient dismissed should I fail to follow.*

First Name*

Last Name*

Date of Birth*

Phone Number*

Do you prefer AM or PM appointment?* AM PM

List all insurance plans*

Insurance Company, Policy, and Group Number*

Email*

City of Residence*

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