Welcome to Christine Meyer, MD and Associates! We are honored that you have chosen to partner with us for your health.
As a new patient, we invite you to tell us about you! This new-patient questionnaire will allow us to build a comprehensive medical chart for you, so we start off strong. We know it is a lot of questions, but take your time and tell us your health story. We're listening.
This questionnaire will take about 20-30 minutes. It is a HIPAA-secure form. You cannot pause and come back later to finish, so take a few minutes to gather any documentation you may need for the details, including:
- Preferred local pharmacy name and Location
- Mail-away pharmacy name and Location
- Emergency contact name, phone, and address
- Medical conditions you have
- Chronic conditions you have
- Other healthcare providers or specialists you see (name and most recent visit)
- Dates of your last: physical exam, colonoscopy, and blood work
- Dates of your last: flu shot, Pneumovax, Prevnar, Tetanus, Shingles vaccine, and any other vaccines
- Surgeries, hospitalizations and ER visits
- Medications you currently take
- Family history (immediate family members who have relevant conditions)
- Females: Date of last period, Pap smear, gyn exam, mammogram
- Males: Date of last PSA screening and prostate exam
Wait! Before completing this paperwork, please contact your insurance company to be sure we are in-network or affordable to you out-of-network. We accept most major insurances. We do not accept Medicaid, nor do we enroll private/cash-pay patients (paying entirely out of pocket). We are not in-network with many EPO (Exclusive Provider Organization) and multi-plan insurances. We accept patients for whom we are out-of-network, but your copays may be higher. Before completing your New Patient paperwork to enroll as a patient, please call your insurance company to be sure we are in-network or affordable to you out-of-network.
This questionnaire should also be completed after you have spoken with our team and booked your first appointment. To begin, tell us: