Telemedicine: New Patient Application Please enable JavaScript in your browser to complete this form.Full Name: *FirstMiddleLastDate of Birth: *Gender:MaleFemaleLGBTQ+Marital Status:MarriedSingleDivorcedWidowedOtherPrimary Language:EnglishSpanishOtherRace:Black (Non-Hispanic)HispanicAmerican Native /AlaskanWhite (Non-Hispanic)Asian and Pacific IslanderOtherHome Address:City *State *Zip Code *Phone Number *Email AddressOccupationHow did you hear about us? *FacebookGoogleWebsiteWord of MouthAnother FacilityInsuranceOtherPrimary Care PhysicianPrimary Physician NamePrimary Physician Phone NumberStreet AddressCityStateZip CodeEmergency ContactEmergency Contact NameRelationPhone NumberAddressInsurance InformationInsurance Company #1Plan Name #1Policy Number #1Policy #1 Holder NameInsurance Company #2Plan Number #2Policy Number #2 Policy #2 Holder NameChronic ConditionsPlease list any chronic conditionsSocial HistoryPlease check all that apply:Drink AlcoholDrink Caffeinated BeveragesTake Non-Prescribed DrugsEmployedDisabledSmokeVapeUnder More Than Normal StressPlease list ALL medications and supplements you are currently takingPlease list any allergies to medications or foodsPharmacy InformationPlease 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 NamePharmacy PhonePharmacy AddressCity, State, ZipSubmit
