Telemedicine - Partners Family Medicine

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LOCALLY OWNED & OPERATED

4453 HIGHWAY 90 PACE, FL 32571

(850) 905-0110

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About
Services
Payment Options
Telemed
New Patient Applications
Blog
Contact
Patient Portal
Request an Appointment

Telemedicine: New Patient Application

Full Name: *

First

Middle

Last

Date of Birth: *

Gender:

Male
Female
LGBTQ+

Marital Status:

Married
Single
Divorced
Widowed
Other

Primary Language:

English
Spanish
Other

Race:

Black (Non-Hispanic)
Hispanic
American Native /Alaskan
White (Non-Hispanic)
Asian and Pacific Islander
Other

Home Address:

City *

State *

Zip Code *

Phone Number *

Email Address

Occupation

How did you hear about us? *

Facebook
Google
Website
Word of Mouth
Another Facility
Insurance
Other

Primary Care Physician

Primary Physician Name

Primary Physician Phone Number

Street Address

City

State

Zip Code

Emergency Contact

Emergency Contact Name

Relation

Phone Number

Address

Insurance Information

Insurance Company #1

Plan Name #1

Policy Number #1

Policy #1 Holder Name

Insurance Company #2

Plan Number #2

Policy Number #2

Policy #2 Holder Name

Chronic Conditions

Please list any chronic conditions

Social History

Please check all that apply:

Drink Alcohol
Drink Caffeinated Beverages
Take Non-Prescribed Drugs
Employed
Disabled
Smoke
Vape
Under More Than Normal Stress

Please list ALL medications and supplements you are currently taking

Please list any allergies to medications or foods

Pharmacy Information

Please note, this pharmacy will be used for all future medications that may be prescribed by your medical provider at Partners Family Medicibe Practice & Recovery Center.

Pharmacy Name

Pharmacy Phone

Pharmacy Address

City, State, Zip

GET IN TOUCH WITH US

Location

4453 HIGHWAY 90
PACE, FL 32571

Phone

(850) 905-0110
(850) 427-8600

Email

admin@familymedicineandaddiction.com

SEND A MESSAGE

Name *

First

Middle

Last

Email

Phone *

City *

State *

Zip Code *

Services Interested In: *

Family Medicine
Behavioral Health
Addiction Recovery
Telemedicine Services.

Message *

CALL US: (850) 905-0110

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Home
About
Services
Payment Options
Telemed
Blog
Contact

About
Services
Payment Options
Telemed
New Patient Applications
▼
Blog
Contact
Patient Portal
Request an Appointment

Partners Family Medicine