New Primary Care Patient Intake Form

Name *

First

Last

Date of Birth *

Gender *

Pronoun(s) *

Phone Number *

Email *

Do we have your consent to send text, email and voice messages regarding your appointments? *

Yes
No

Do we have your consent to email you sensitive medical information, including your lab results, referrals, and lab orders from our HIPPA – Secure email address? *

Yes
No

Entire Home Address (Street Address Apt # City, State, Zip Code) *

Please type in your FULL address above

Emergency Contact: First and Last Name *

Emergency Contact: Relationship and Phone Number *

Medical Insurance Name (INSURANCE PLANS NOT ACCEPTED – CIGNA, MOLINA, AM BETTER/ COORDINATED CARE, UNITED HEALTHCARE, PREMERA HMOs, MEDICARE, PREMERA MEDICARE ADVANTAGE PLAN, HUMANA) *

PLEASE EMAIL US A PICTURE OF THE FRONT & BACK OF YOUR MEDICAL INSURANCE CARD AT FRONTDESK@PHINNEYPCW.COM

Insurance ID (with Prefix) *

Insurance Group # (if none type in NA) *

Primary Subscriber's First & Last Name – Medical Insurance *

Primary Subscriber's Date of Birth *

Email pictures of medical insurance card to frontdesk@phinneypcw.com *

I have emailed pictures (front & back) of my insurance card(s) to frontdesk@phinneypcw.com
I do not have medical insurance. I will pay out of pocket

Note- This is REQUIRED to move forward with your request.

Which provider would you like to see? *

Peter Grote, MD (Membership)
David Harvey, MD (Membership)
Kerri Dansby ARNP
Megan Melo, MD ( Weight Management ONLY)
Elizabeth Goldberg ARNP PhD IFMCP (Membership)
Do Not Have A Preference

Have you had an annual wellness exam / check up in the past 12 months? *

Please respond YES below if you are transferring care from Ballard Neighborhood Doctors' clinic. *

Were you referred by someone? If so, by who (name)? *

Reason for the Appointment Request *

Visit Type *

In Office visit
Telemed/Virtial Visit
No Preference

Preferred Pharmacy – Name and Address *

Are you looking for a new dentist for yourself or your child(s) in the Phinney neighborhood? Click yes to receive more information. *

Yes
No

Phinney Primary Care & Wellness

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