New Patient Registration 
We are located at 32128 Broken Branch Circle Spanish Fort, Alabama 36527!  

Once I receive all of this information back I will call and get your appointment scheduled for you. (This could take a day or two depending on the workflow in office) 

PLEASE READ THE FOLLOWING:

Our services we offer: Primary Care, Gynecology, Hormone Therapy

You cannot have 2 primary care providers, your insurance will not allow this. 

The insurance we DO NOT take are Christian Care Ministry, Medicaid and Viva Health. 

Weight Loss: BMI has to be greater than 30 or 27 if you have comorbidities like high blood pressure, diabetes, elevated cholesterol. (No exceptions to BMI requirements) 


WHAT TO EXPECT:
On this visit we will obtain vital signs, BMI, review past medical history get a list of your current problems, medications, obtain baseline labs and perform a head to toe physical evaluation. Since we are obtaining baseline labs we do request that you come fasting (If possible not a requirement). We will not diagnose any immediate issues you may have, that will come at the follow up appointment. Copays are required for these visits. We will not bill this visit as a annual exam. 

**We do have a no show/cancellation policy that we will enforce for all new and existing patients. This includes a $50 charge for canceling or rescheduling within 24 hours of your scheduled appointment and no shows. 

 **Our new patient labs are NOT considered 'preventative care' labs. It is your responsibility to contact your insurance and find out what they do and do not cover for laboratory testing. The lab we have in place is an outside agency and we have nothing to do with their billing processes, you would contact them directly if you receive a bill regarding labs.
 
WE REQUIRE ALL PATIENTS TO BE FULLY VACCINATED. YOU CAN CHOOSE A DELAYED VACCINATION SCHEDULE BUT YOU HAVE TO BE VACCINATED. ** This does NOT include the COVID vaccines**


Please answer all of the following questions. 

Sign in to Google to save your progress. Learn more
Please watch our new patient video. It will answer all your questions!
Last Name: *
First Name: *
Nickname:
Date of Birth: *
MM
/
DD
/
YYYY
Gender: *
Address: (Street, City and Zip Code) *
Phone Number: *
Email: *
Insurance Plan Name: *
Policy / ID Number: *
Secondary Insurance Name:
Policy / ID Number:
What are you looking for? *
How did you hear about us?  *
We do require that a debit/credit card is on file. That card will not be charged unless you NO SHOW or CANCEL WITHOUT a 24 hour notice. 

The fee is $50.00
*
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy