New Patients

Falsifying or excluding any information about your medical history may result in your dismissal from any of the primary care practices listed below.

Patient First Name*

Patient Middle Name

Patient Last Name*

Date of Birth*

Gender*

Address Line 1*

Address Line 2

City*

State*

Zip*

Contact Name (if not patient)

Email Address*

Phone Number*

If patient is under 18, who is the responsible party?

Are you related to or applying with another family member?*

If so, who? Who is their current primary care provider?

Please list all other health care providers that you routinely see (doctor/specialty)*

Referred By:

Medical History*

Current Medications*

Current Concerns (if any)

Please Select Your Preferred Practice*

(Several practices are accepting limited new patients at this time. While we will try our best to accommodate your practice of choice, please note that we may submit your form to any of the practices listed below in order to connect you with a provider in a timely manner.)

If you have a preferred provider, please include their name here. You may also write any additional comments necessary for the practice.

Do you have a preferred provider gender?*

Have you been a previous patient?*

If so, why did you leave?

Are you willing to use Community Hospital?*

Do you use any tobacco products?*

Do you need a bilingual provider?*

If so, what language?

How soon do you want to be seen?*

Insurance Type:*

Please do not use this area to contact us regarding your personal medical issues. Please call us with questions about your medications or medical treatment. This information is sent to a referral coordinator for new patient forms only. If you are a current patient, please contact your provider.