Patient Information
First Name*:
Middle Name:
Last Name*:
Gender:
Select Gender Female Male
Contact Information
Contact Name (if different than patient name):
Address*:
City*:
State*:
AL AK AR AZ CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV MH NJ MN NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
Zip Code*:
Telephone*:
Email Address:
Insurance Information
Primary Health Insurance
Name:
Please Select Aetna Blue Cross/Blue Shield Humana Medicaid Medicare None Other (specify below) PacificCare Self Pay (Private) Unicare Unknown UT Select (Blue Cross/Blue Sheild)
(Please specify Other)
Primary Health Insurance
Type:
Select One EPO HMO Medicaid Medicaid HMO Medicare POS PPO Other I Don’t Know
Policy # :
Group # :
Primary Holder First Name:
Primary Holder Middle Name:
Primary Holder Last Name:
Primary Holder Name:
Insurance Claim Phone #:
Secondary Health Insurance
Type (if any):
Select One EPO HMO Medicaid Medicaid HMO Medicare POS PPO Other I Don’t Know
Policy # :
Group # :
Insurance Claim Phone #:
Appointment Information
Primary Care Provider or Referring Physician’s Name:
Primary Care Provider or Referring Physician’s Phone Number:
Have you ever had an appointment at Kendall Immediate Care?
Please Select Yes No
Do you have a particular physician that you would like to see?
Yes No
If yes, please enter that physician’s name here:
Have you seen this physician before?
Please Select Yes No
Type of service requested:
Choose Service Pediatric Allergy Pediatric Cardiology Pediatric Child Development Pediatric Diabetes/Endocrinology Pediatric ENT-Otolaryngology Pediatric Gastroenterology Pediatric Genetics Pediatric Hematology/Oncology Pediatric Infectious Diseases Pediatric Nephrology Pediatric Neurology Pediatric Ophthalmology Pediatric Orthopedics Pediatric Special Services/Chronic Care Pediatric Surgery Adult Allergy Adult Cardiology Adult Dermatology Adult Diabetes/Stark Center Adult Endocrine Adult Family Medicine Adult Gastroenterology Adult Geriatric Adult Hematology/Oncology Adult Infectious Disease Adult Nephrology Adult Neurosurgery Adult OB/GYN Adult OB/GYN Women’s Health Care Group Adult Ophthalmology Adult Oral Surgery (not routine dental) Adult Orthopedic Adult Otolaryngology (ENT) Adult Pain Clinic Adult Plastic Surgery Adult Rehab OT/PT Adult Surgery Clinic (Burns, Breast, Vascular) Adult Urology Adult Weight Loss Center
Reason for appointment:
Time Preference
Day of week: Select Day Any Monday Tuesday Wednesday Thursday Friday or
Second Choice (Optional) Monday Tuesday Wednesday Thursday Friday
Time of day: Select Time Preference No Preference Morning Afternoon
Additional comments:
