*Patient's Name
*Address
*City, *State, *Zip
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Lousiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming (Not in U.S.)
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Country
*Date of Birth
Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900
*Gender
Male Female
Social Security Number
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*Health Insurance Provider (HIP)
Select Insurance Coverage First Care Alliance BSA Workmans Compensation- is accepted and reviewed case by case, not accepted currently by our neurologists. BlueCross/BlueShield Medicare Medicaid Other (Enter in box below)
(Other HIP)
*HIP Phone Number
*Insured's Name
Name (if different from patient name)
*Email Address
*Daytime Phone
( ) - Ext.
Evening Phone
Referring Physician (if applicable)
Physician Phone
Physician Address
Have you been a FMC Canyon patient in the past? Yes No
Questions/Comments
*How did you hear about us?
Select from this list Family Medicine Centers Doctor Other Doctor Nurse or Hospital Employee Internet Friend or Relative Flyer or Poster Newspaper Radio Television Other
*Please indicate what time of day you would prefer your appointment (check as many options as possible). All times are Central Standard Time (USA)
Morning:
8-9 am
9-10 am
10-11 am
11 am-12 noon
Afternoon:
12-1 pm
1-2 pm
2-3 pm
3-4 pm
4-5 pm
5-6 pm
The appointment coordinator will contact you within 24 hours with information about your request. If you submit your request on a holiday or Friday afternoon through Sunday, we will respond by the end of the next business day.
If you do not hear from us within this timeframe, please contact us at 806-655-2104. You acknowledge the risk of sending this information by email and agree not to hold Family Medicine Centers liable for any damages you may incur as a result of the transfer or use of this information. The use or transmittal of this form does not create a physician-patient relationship. More information regarding the confidentiality of this request can be found in our Appointment Request Privacy Policy.