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New Primary Care Patient Intake Form
April 4, 2023
/
Amna Mirza
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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
Entire Home Address (Street Address Apt # City, State, Zip Code)
*
Please type in your FULL address above
Medical Insurance Name (PLEASE NOTE: PATIENTS ARE RESPONSIBLE TO ENSURE THAT THEIR MEDICAL INSURANCE IS ACTIVE AND IN-NETWORK WITH THE CHOSEN PROVIDER AT OUR CLINIC. PLEASE CALL YOUR INSURANCE TO CHECK.)
*
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.
Reason for the Appointment Request
*
Visit Type
*
In Office visit
Telemed/Virtial Visit
No Preference
Are you looking for a new dentist for yourself or your child(s) in the Phinney neighborhood? Click yes to receive more information.
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No
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