NEW PATIENT CONTACT INFORMATION

If you have a life threatening emergency please dial 911 or go to the nearest emergency room. You may also visit our website for other local sources of urgent care.

What is your reason for seeking care at this time? *

Date of Birth *

Date

Name *

First Name Last Name

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Phone Number *

Please enter a valid phone number.

Email

example@example.com

ALL NEW PATIENTS ARE REQUIRED TO HAVE A PRIMARY CARE PHYSICIAN. WHO IS YOUR CURRENT PRIMARY CARE PHYSICIAN? IF NONE TYPE "NONE" *

MAY WE CONTACT THEM TO VERIFY YOU ARE AN ACTIVE PATIENT WITH THIER OFFICE? *

YES NO I DON'T HAVE A PRIMARY CARE PHYSICIAN

WHAT TYPE OF INSURANCE DO YOU CURRENTLY HAVE? PLEASE LIST THE NAME OF THE INSURANCE EVEN IF YOU PLAN ON SELF-PAYING FOR THE OFFICE VISITS. IF NONE TYPE "NONE" *

WHAT IS THE POLICY # (IF YOU HAVE MEDICARE LIST YOUR MEDICARE #) EVEN IF YOU PLAN ON SELF-PAYING FOR THE OFFICE VISITS. IF NONE TYPE "NONE" *

MAY WE CONTACT THEM TO VERIFY YOUR INSURANCE IS ACTIVE? *

YES NO I DON'T HAVE INSURANCE

WHAT ARE YOUR CURRENT MEDICATIONS AND DOSES? Type "none" if noe. *

MAY WE VERIFY ANY CONTROLLED PRESCRIPTIONS ABOVE AS ACTIVE BY CONTACTING THE FLORIDA DRUG ENFORCEMENT AGENCY? *

YES NO

ARE YOU AVAILABLE FOR TELEMEDICINE APPOINTMENTS? IF SO, HOW? *

SMART PHONE WITH CAMERA - I CAN DO TELEMEDICINE COMPUTER WITH CAMERA AND MICROPHONE - I CAN DO TELEMEDICINE I CANNOT DO TELEMEDICINE AT THIS TIME I DON'T KNOW IF I CAN DO TELEMED.

If we are unable to accept you at a patient at this time you will receive the following message in your manner of choice below.

Thank you for reaching out to John W. Grace, M.D.,P.A. After reviewing your submitted information and based upon our current practice availability and resources, we are unable to accept you as a patient at this office at this time.
Please check back with us in six months as we are frequently adjusting our practice in these complicated times.

Sincerely,

John Grace, M.D.

If we are unable to schedule you at this time, how would you like to receive the above message. *

Please mail above message to my address above. Please leave above message on my voicemail for phone number above. No reply is necessary if you are unable to see me at this time. If I do not hear from you within two weeks, I will understand that you are unable to schedule me at this time.

If we are able to schedule you, you must review our policies, general instructions, and complete an initial evaluation packet. How would you like to receive this information?

Please give me the establishment paperwork by: *

(Fastest) Texting me a link to the above phone number. Mailing me a letter with the link to fill out online. Call me for a time to come and pick up all of the required paperwork.

SELF-PAY COST

$505.00

DUE PRIOR TO SCHEDULING

If we do not accept your insurance, you will have to prepay $505.00. This covers the first visit cost ($275.00) and two follow up visits at weeks 1 and 3. ($120.00 each).

New patients are automatically given a follow up at 1 week and 3 weeks to monitor the progress of their initial care and instructions. These visits must be prepaid prior to the first visit for self-pay patients. Any unused visit costs are refunded.

By signing below I understand and accept the above submission. *

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