New Patient Registration

We are accepting new patients! If you are looking for a family doctor you can trust to take care of you and your family, find out why we are the place for you. Read more about our clinic here.

If you are a new patient, please complete the New Patient Check-In Sheet below. Can be completed on computer or phone. Once we receive your information, we will call you to schedule an appointment.

We do not take any insurance or government payments; we are a direct-pay clinic. If you are uninsured, our clinic is a great option. However, we can see anyone, regardless of insurance status.

If you have questions or need to send us additional information, see our contact information.

Don't want to use the form below? Go here to use the downloadable forms.

Medical care can be affordable! We have great prices.

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New Patient Check-In/Registration Sheet (complete separate form for each patient)

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Full Legal Name: *

Nickname/Preferred Name:

Gender (M, F): *

E-mail address: *

Home Phone: *

Mobile Phone:

Preferred method of communication (home phone, mobile, email) *

Date of Birth: *

If minor, names of parents or guardians: *

Name of insurance or cost-sharing program (name only), or write "none": *

Full address: *

In case of emergency whom should we contact (name, relationship, phone)?: *

With whom may we discuss your personal medical information (name, relationship)?: *

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