Becoming a new patient

Unfortunately we are closed to New Patients. Fill out this form if you would like to be placed on our waiting list!

Please fill out the information in this form and we will contact you when a New Patient visit becomes available. (New Patient visits require a longer appt. slot - as we will be going over your medical information and medical history with you.) We do not have an expected wait time currently.

We are presently out 6 Months - Only sign up if you are ok to wait that long.

Thank you for your interest in becoming a new patient!

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First and Last Name *

Date of Birth (use calendar for proper format) * +

Phone Number *

Address *

City *

Zip Code *

State *

Address Line 2

Email Address *

Today's date * +

With your current Insurance, have you had a well visit within the last year? *

Yes

No

What would the reason for your visit be? *

Please list any current prescription medications you are taking: (Per PA guidelines, please be aware we do not prescribe controlled substances on a routine daily basis. However, we will prescribe rescue medications as needed. Examples: Xanax, Ativan, Oxycodone) *