Grand Valley Primary Care
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New Patients
Falsifying or excluding any information about your medical history may result in your dismissal from any of the primary care practices listed below.
Fields in
bold
are required.
Gender:
Male
Female
Are you related to another patient in the practice?
Yes
No
If so, who?
Is your insurance through a Community Health Partnership (CHP) plan? If yes, please select the employer below:
No
School District 51
Mesa County
Community Hospital
Strive
If no, are you part of Anthem's Mountain Enhanced Network (MEN) insurance through your employer?
Yes
No
Please list all other health care providers that you routinely see (doctor/specialty)
Medical History
Current Medications
Current Concerns (if any)
Do you have a preferred practice?
(Several practices are accepting limited new patients at this time. While we will try our best to accommodate your practice of choice, please note that we may submit your form to any of the practices listed below in order to connect you with a provider in a timely manner.)
Grand Valley Primary Care - 603 28 ¼ Road, Grand Junction
Grand Valley Primary Care - 2020 North 12th Street, Grand Junction
Grand Valley Primary Care - 2478 Patterson Road, Unit 27, Grand Junction
Grand Valley Primary Care - Palisade – 731 Iowa Avenue, Palisade
Internal Medicine Associates - 607 28 ¼ Road, Grand Junction (Patients over 18 yrs only)
Grand Valley Primary Care – Fruita - 101 Jurassic Ave, Fruita
Western Medical Associates of the Grand Valley- 743 Horizon Court, Suite 100, Grand Junction
Do you have a preference in provider?
No Preference - Whichever provider has the earliest openings for new patient appointments
Male Provider
Female Provider
Do you need a bilingual provider?
Yes
No
If so, what language?
How soon do you want to be seen?
Select one
Less than a month
Next annual
Other
Submit Form
