PATIENT DETAILS

Patient Name

First

Last

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Date of Birth

Sex

Email

We will never rent or sell your email address - we value your privacy.

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Cell Phone Number

Home Phone Number

Mailing Address

Address Line 1

Address Line 2

City

State

Zip Code

Marital Status

Your Employer Name

Leave empty if not currently employed.

Reason For Appointment

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PATIENT DEMOGRAPHIC

EMERGENCY CONTACT INFORMATION

Emergency Contact's Name

First

Last

Contact Number

Relation to Patient

May We Send Them Information?

MEDICAL INSURANCE INFORMATION

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Insurance Company

ID Number

Policy Holder Name

First

Last

Relationship to Patient

Policy Holder's Address

Address Line 1

Address Line 2

City

State

Zip Code

Policy Holder Employer

Policy Holder's Birth Date

PHARMACY INFORMATION

Recommended Pharmacy

Yes
No

I would like to use ICM Cares recommended pharmacy (Walmart, Germantown). If not, please provide your pharmacy information below.

Preferred Pharmacy

Address of Pharmacy

Prescription Consent

Yes
No

I give ICM Cares Clinic permission to write prescriptions on my behalf.

CONSENT FOR SMS COMMUNICATION

I voluntarily consent to receive SMS (TEXT) communication from ICM Cares Clinic.

SMS Consent

Checkboxes

Yes
No

Please choose an option.

CONSENT FOR TREATMENT

I voluntarily consent to any and all health care treatment and diagnostic procedures provided by ICM Cares Clinic and its associated physicians, clinicians, and other personnel. I am aware that the practice of medicine and other health care professions is not an exact science and I further state that I understand that no guarantee has been or can be made as to the results of the treatments or examinations at ICM Cares Clinic.

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Patient or Authotized Person's Name

First

Last

Date

Checkboxes

First Choice
Second Choice
Third Choice

Contact Us

Have a Question? Send us a note

Location

Map

New Patient Appointment Form

PATIENT DETAILS

PATIENT DEMOGRAPHIC

EMERGENCY CONTACT INFORMATION

MEDICAL INSURANCE INFORMATION

PHARMACY INFORMATION

CONSENT FOR SMS COMMUNICATION

I voluntarily consent to receive SMS (TEXT) communication from ICM Cares Clinic.

CONSENT FOR TREATMENT