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
Insurance
Aetna
Blue Cross Blue Shield
CHP+
Cigna
Medicaid
Medicare
Medicare Advantage
Rocky Mountain Health Plans
United Healthcare
Other
Are you related to or applying with another family member?
Yes
No
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?
Yes
No
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?
Yes
No
Referred by:
Do you use any tobacco products?
Yes
No
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.)
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
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.
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