3201 W Peoria Ave, Ste D804, Phoenix, AZ 85029 Mon–Fri 9am–5pm
602-569-5437 Fax 855-583-3686
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Family practice intake

New Patient Form

Complete the form below and hit send — it goes straight to our front-desk team, so we can have your chart ready before you arrive. Fields marked * are required.

Please note: This form is for new patient registration and is not for emergencies. If this is a medical emergency, call 911. Prefer paper? Use the Print / Save as PDF button to print a blank copy and bring it with you.
1 Patient information
2 Parent or guardian (if patient is under 18)
3 Emergency contact
4 Insurance
5 Pharmacy & reason for visit
6 Medical history
7 Medications & allergies
8 Family & social history
9 Acknowledgment & signature

By submitting this form, I certify that the information provided is accurate to the best of my knowledge. I understand this form is a registration request and does not establish care until confirmed by the office. I acknowledge that I have been offered the clinic's Notice of Privacy Practices.

Please avoid including especially sensitive details (such as full Social Security or financial account numbers) in this online form. We'll collect anything else we need securely at your visit.