Primary Care Application

Primary Care Enrollment for Long-Term Wellness

First name

Last name

Birthday

Day

Month

Year

Phone Number

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Best Time of Day to Contact

How did you hear about us?

Primary Reason for Primary Care

Have you had a primary care doctor previously?

Yes

If so, what was the reason for leaving?

Are you taking any prescribed medications? If so, list them below

Include pertinent information, i.e. frequency, date prescribed, etc.

Medical Insurance Carrier

Are there any concerns you would like your provider to be aware of?