PATIENT DETAILS

Patient Name *

First

Last

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Date of Birth *

Sex *

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

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Language *

Race *

African American
American Indian/Alaska Native
Asian
White
Mixed Race
Other
Refuse to Report

Marital Status *

Ethnicity *

Hispanic
Not Hispanic
Refuse to Report

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: Walmart, Germantown MD

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

Walmart Germantown Address: 20910 Frederick Rd, Germantown, MD 20876

Preferred Pharmacy *

Address of Pharmacy

Prescription Consent *

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

CONSENT FOR SMS COMMUNICATION

ICM Cares Clinic may message you with information regarding your health visit or prescription updates.

SMS Consent

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

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

New Patient Information Form

PATIENT DETAILS

PATIENT DEMOGRAPHIC

EMERGENCY CONTACT INFORMATION

MEDICAL INSURANCE INFORMATION

PHARMACY INFORMATION

CONSENT FOR SMS COMMUNICATION

CONSENT FOR TREATMENT