Telemed Recovery Patient Application - Partners Family Medicine

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1-800-417-7371

New Patient Application

Please fill out the form below and one of our staff members will be in contact with you to help walk you through the next steps. Any information you share with us is kept private.

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

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