Appointment Request For New Patients


To request a physician appointment, please enter the information requested and click the “Send Appointment Request” button at the bottom of the form.


Patient First Name: *
Preferred Name:  
Patient Last Name: *
Contact / Parent / Guardian Name:  
Street Address: *
Apt / Suite:  
City: *
State: *
Zip Code: *
Email Address: *
Patient Gender: *
Patient Date of Birth: *
Social Security Number:  
Primary Phone: *
Alternate Phone:  
Personal Physician:  
Seen before at Andrews Institute?  
Reason for appointment and/or concern? *
Date of injury or onset of symptoms?  
Previous Treatment  
Any diagnostic testing for this medical issue?  
Past surgery for this medical issue?  
Do you smoke?  
Are you diabetic?  
List name/dosage for all pain medications currently taking:  
Primary Medical Insurance:  
Member ID Number:


Group Number:


PO Box / Address:
 
Primary Cardholder Name (if not patient):



Primary Cardholder DOB (if not patient):

 
Secondary Medical Insurance:  
Member ID Number:


Group Number:


PO Box / Address:
 
Is this a worker’s comp / auto accident injury?  
Litigated?  
Name of Attorney:  
How did you hear about us? *
Other:  

Privacy Statement: All information will remain confidential and will not be released to any group outside of Baptist Health Care.