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.

   Are you related to or applying with another family member?  

   If so, who? Who is their current primary care provider?
   If patient is under 18, who is the responsible party?
   Please list all other health care providers that you routinely see (doctor/specialty)
   Medical history for the past 10 years
   (This is important for finding a provider who is knowledgeable with treating any conditions you may have.)
   Have you been a previous patient?  
   If so, why did you leave?
   Current medications
   Please provide an accurate list of medications you are currently taking. Medication omissions may result in denial of application.
   Are you willing to use Community Hospital?  

   Referred by:
   Do you use any tobacco products?  
   If you have a preferred provider, please include their name here. You may also write any additional comments necessary for the practice.
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.)

Do you have a preference in provider?

Do you need a bilingual provider?  

   If so, what language?
How soon do you want to be seen?
Please do not use this area to contact us regarding your personal medical issues. Please call us with questions about your medications or medical treatment. This information is sent to a referral coordinator for new patient forms only. If you are a current patient, please contact your provider.