New Patient Information Form

All patients must complete a patient information form prior to their appointment and to receive medical service. You may download the form, fill it out, and present it during your appointment. You can also complete the form below and submit it online before your appointment.

IMPORTANT INFORMATION BEFORE MAKING AN APPOINTMENT

1. If you speak Spanish as your first language, consider scheduling your visit on Saturday between 9am – 5pm. 
2. If French is your first language, consider scheduling your visit on Saturday between 9am – 5pm, or Tuesday between 9am – 5pm. 
   1. We have providers on these days that speak French and/or Spanish 
3. before coming to your appointment, be sure to bring your ID. Also bring an accurate / up to date list of medications if applicable. 
4. we serve patients aged 18+ years, with and without medical insurance
5. Our visit copay is $30. We also have discounted rates on blood tests and imaging through Quest Diagnostics and Adventist Health

Notice: By completing the intake form you agree to opt in to being contacted by ICM Cares Clinic through SMS or email.

Complete the form below before your appointment.