Request To Be Our Primary Care Patient

We want to be sure that we can provide the best possible care to you. Please fill this information out for us to review your medical history. We will get back to you shortly.

All annual physical exams will only be performed at our Steele Creek office. You can visit either of our office for the sick visit or an injury.

First Name *

Last Name *

Date of Birth *

Gender *

Male

Female

Other

Phone *

Email Address *

Emergency contact name *

Emergency contact phone number *

Health Insurance *

Are you currently up-to-date on all the vaccines? *

Do you have any past medical history of any chronic disease? *

Are you currently on any prescription medications? *

Do you need refills for any prescription medications? *

Have you had any surgeries or any major procedure done in the past? *

Do currently or previously smoke tobacco, drink alcohol or used any illicit drug? *

Any family history of cancer, Heart disease, diabetes, genetic disorders? *

Do you have any acute health concerns today? *

I certify that the above facts are true to the best of my knowledge and belief and I understand that I subject myself to be dismissed from the practice in the event that the above facts are found to be falsified.

I agree with OneSpotMD Primary and Urgent Care PLLC's Primary Care Patient Policy,

Full Name *

Today's date *

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