New Patient Form

New Patient Enrollment
Do you live in one of the following states?*

ColoradoConnecticutFloridaIllinoisIowaKansasMaineMinnesotaNew HampshireNew MexicoNew YorkOhioRhode IslandVirginiaWest VirginiaNone of these
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Sex*
Contact Number:*
E-mail*
example@example.com
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Marital Status*
In case of emergency
Emergency Contact:*

First NameLast Name
Relationship*
Contact Number*
Taking any medications, currently?*

YesNo
If yes, please list it here. Otherwise type N/A*
Allergies (If no, mark N/A)*
Reason for visit*

Acute careChronic careWeight LossPhysical (School, Work, DOT)Travel Health (consultation and medication)Vaccines (COVID and Yellow Fever Only)Other
If other, list here
Insurance (If none, type N/A)*
Subscriber ID (If none, type N/A)*
Group Name (If none, type N/A)*
Type a question*

SelfSpouseChildDomestic PartnerGuardianOther
Secondary Insurance
Subscriber ID
Group Number
Relationship to Subscriber

SelfSpouseChildDomestic PartnerGuardianOther
Pharmacy Name*
Pharmacy address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Upload a copy of your photo ID*
Privacy Policy

Terms and Conditions
Do you agree with the Privacy Policy and Terms and Conditions?*

I AGREEI DO NOT AGREE
Signature*

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New Patient Enrollment