Help Me Find a Provider

Help Me Find a Provider
If you do not currently have a primary care provider, or would like to find a new provider, please take a moment to fill out this form. A Good Samaritan representative will then contact you within three business days to help you get set up with a new provider.
Name

First NameLast Name
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number
Please enter a valid phone number.
Date of Birth

MonthDayYear
Date
Have you previously been a patient of Good Samaritan Physician Network?

YesNo
What area of providers are you interested in?

Internal Medicine - Internal medicine is the medical specialty dealing with the prevention, diagnosis, and treatment of internal diseases in adults.Family Practice - A medical specialty within primary care that provides continuing and comprehensive health care for the individual and family across all ages, genders, diseases, and parts of the body.Pediatrics - A medical specialty dealing with the health and medical care of infants, children, and adolescents from birth up to the age of 18.I don't know
I prefer a:

DoctorNurse PractitionerPhysician AssistantResidentDoesn't Matter
I prefer a:

MaleFemale
What is the best time of day to reach you? (Select all that apply)

8 a.m. to 10 a.m.10 a.m. to NoonNoon to 2 p.m.2 p.m. to 3 p.m.3 p.m. to 5 p.m.
Comments
How did you find this appointment request form?

Good Samaritan Heart Health Risk AssessmentGood Samaritan WebsiteGood Samaritan Facebook PageOther
Thank you for choosing Good Samaritan as your healthcare provider.

If you are having a medical emergency, call 911 or emergency medical help.
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